Certification of Balloting {NJB NB}

UNITED STATES BANKRUPTCY COURT DISTRICT OF NEW JERSEY Caption in Compliance with D.N.J. LBR 9004-1(b) In Re: Case No.: Chapter: __________________ 11 Hearing Date: __________________ Judge: __________________ CERTIFICATION OF BALLOTING Impaired Yes/No Number of Ballots Cast Number of Ballots Accepting Number of Ballots Rejecting Percentage of Ballots Accepting Dollar Amount of Ballots Accepting Dollar Amount of Ballots Rejecting Percentage of Dollar Amount Accepting Accept Yes/No CLASS I CLASS II CLASS III CLASS IV CLASS V CLASS VI ** Add additional classes as necessary. American LegalNet, Inc. www.FormsWorkFlow.com If any ballots have not been included in this tally, provide an explanation: I, ______________________________, the attorney for the, or self represented plan proponent in this case, certify under penalty of perjury that the above is true. Date: _______________________ ______________________________ Signature new.8/1/15 2 American LegalNet, Inc. www.FormsWorkFlow.com