R.I. Local Form 3018-1.1 UNITED STATES BANKRUPTCY COURT DISTRICT OF RHODE ISLAND ) ) BK No. ) ) REPORT ON BALLOTS CHAPTER 11 PLAN CREDITORS BALLOTS VOTING CLASS OF CREDITORS Class NUMBER I. II. III. IV. V. VI. VII. DESCRIPTION QUANTITY DOLLAR VALUE QUANTITY IN RE: Debtor(s) YES DOLLAR VALUE *** NO QUANTITY *** Ballots voting YES represent at least one-half (1/2) in quantity and more than two-thirds (2/3) in dollar value of the allowed claims voting in this Class. Check the above box (***) if this applies. American LegalNet, Inc. www.FormsWorkFlow.com Use additional sheet if necessary. Complete the Form for as many Classes as appropriate. PAGE TWO OF REPORT ON BALLOTS: IN RE: Debtor(s) ) ) ) ) ) BK No. List separately any ballots filed after the ballot deadline showing the same information as above. (Debtor's Name) (Attorney's Name) State Bar No. (Address) (TEL:) (FAX:) Dated: American LegalNet, Inc. www.FormsWorkFlow.com