**UNITED STATES BANKRUPTCY COURT**

**DISTRICT OF VERMONT**

**In re:**

> **Debtor(s)**

**[SUMMARY BALLOT REPORT AND CERTIFICATION]{.underline}**

\[*Note: Refer to Vt. LBR 3018-3; Vt. LBR 3020-1.*\]

NOW COMES \[the Plan Proponent\], by and through its attorney \[name of
attorney\] and hereby summarizes, reports and certifies to the Court the
results of the balloting on the \[Plan Proponent\]'s Chapter 11 Plan of
Reorganization (hereinafter, "Plan"), dated \[date\], and in making such
report states as follows:

***TIMELY and UNTIMELY FILED BALLOTS***

1.  Of \[#\] of ballots issued, there were \[number (#)\] filed, with
    \[number (#)\] being timely and \[number (#)\] being untimely;

2.  Of the timely-filed ballots, \[number (#)\] accepted the Debtor's
    Plan and \[number (#)\] rejected the Plan.

***SUMMARY OF BALLOTING BY CLASSES***

1.  Class \[#\] \[Name or Identity of Class\]:

> This class is impaired, has voted upon the Plan, and
> \[ACCEPTS/REJECTS\] the Plan.

  ----------------- -------------------------- --------------------------
  **Class \[#\]**   **Ballots**                **Claims in terms of \$**

  Total in Class    \[# of ballots             \[\$ amount of allowed
                    distributed\]              claims\]

  \# Filed          \[# of ballots\] \[(% of   \[\$ amount\] \[(% of
                    total)\]                   total)\]

  For Plan          \[# of ballots\] \[(% of   \[\$ amount\] \[(% of
                    total)\]                   total)\]

  Against Plan      \[# of ballots\] \[(% of   \[\$ amount\] \[(% of
                    total)\]                   total)\]
  ----------------- -------------------------- --------------------------

2.  Class \[#\] \[Name or Identity of Class\]:

> This class is impaired, has voted upon the Plan, and
> \[ACCEPTS/REJECTS\] the Plan.

  ----------------- -------------------------- --------------------------
  **Class \[#\]**   **Ballots**                **Claims in terms of \$**

  Total in Class    \[# of ballots             \[\$ amount of allowed
                    distributed\]              claims\]

  \# Filed          \[# of ballots\] \[(% of   \[\$ amount\] \[(% of
                    total)\]                   total)\]

  For Plan          \[# of ballots\] \[(% of   \[\$ amount\] \[(% of
                    total)\]                   total)\]

  Against Plan      \[# of ballots\] \[(% of   \[\$ amount\] \[(% of
                    total)\]                   total)\]
  ----------------- -------------------------- --------------------------

3.  Class \[#\] \[Name or Identity of Class\]:

This class is impaired, has balloted upon the Plan, and
\[ACCEPTS/REJECTS\] the Plan.

  ----------------- -------------------------- --------------------------
  **Class \[#\]**   **Ballots**                **Claims in terms of \$**

  Total in Class    \[# of ballots             \[\$ amount of allowed
                    distributed\]              claims\]

  \# Filed          \[# of ballots\] \[(% of   \[\$ amount\] \[(% of
                    total)\]                   total)\]

  For Plan          \[# of ballots\] \[(% of   \[\$ amount\] \[(% of
                    total)\]                   total)\]

  Against Plan      \[# of ballots\] \[(% of   \[\$ amount\] \[(% of
                    total)\]                   total)\]
  ----------------- -------------------------- --------------------------

Summary Ballot Report & Certification (continued)

In re:

Case No.:

\[PROVIDE AS MANY ADDITIONAL SUMMARY PARAGRAPHS AS NECESSARY.\]

***CERTIFICATION***

I certify that the \[Plan Proponent\] retains the voted ballots and upon
request of the Court, the debtor-in-possession, the case trustee (if
any), and/or the Office of the U.S. Trustee, copies of such ballots
shall be provided. I further certify that the above summary report is an
accurate summary of all classes, all allowed claims and of all ballots
voted and that this summary complies with Vt. LBR 3018-3.

DATED this \[day\] of \[month\] \[year\] at \[location\].

\[Authorized Agent of Plan Proponent\]

By: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\[Printed Name of Signatory\]

\[Address\]

\[E-mail address\]

\[Phone #\]

\[Fax #\]