UNITED STATES BANKRUPTCY COURT DISTRICT OF NEW HAMPSHIRE In re: _________________________________, Debtor Bk. No. ________-_________-_______ Chapter 11 CERTIFICATE OF VOTE _______________________, the Plan Proponent, by and through attorney ____________________, hereby certify the voting by the holders of claims in Class ____, an impaired class entitled to vote, as follows: Number Voting Accept Reject Total Classes __________________ are not impaired and are deemed to have accepted the plan. Dollar Amount Percentage Percentage Date: ___________________ ____________________________________ Signature ____________________________________ Print Name Address_____________________________ ____________________________________ Tel. No._____________________________ LBF 3018-2 (Eff. 2/1/13) American LegalNet, Inc. www.FormsWorkFlow.com