Affidavit - Solicitation of Proxies



State of _________________

County of ______________

 

I, __________________________________, being first duly sworn, depose and say:

1. My name is ____________________________________________.

2. I am engaged in the ___________________________ business and my office address is ______________________________________________________________

3. I desire to vote proxies for the following claims in the following amounts at the meeting of creditors of _________________________________________________, above-named debtor, to be held on ______________ (date).

4. A copy of the solicitation of each of the proxies is attached.

5. No consideration has been paid or promised by the affiant proxy holder for the proxies.

6. There is no agreement between the proxy holder and any other person for the payment of any consideration in connection with voting the proxy, or for the sharing of compensation with any person, or for the employment of any person as attorney, accountant, appraiser, auctioneer, or other employee for the estate or, if there is an agreement, other than one to share compensation with a member or regular associate of the proxy holder s law firm, state that there is an agreement and give particulars.7. __________ (If the proxy was solicited by a person other than the proxy holder: A statement signed and verified by the solicitor that no consideration has been paid or promised by the solicitor for the proxy and a statement _______________ (state as in paragraph 6) is attached).

8. __________ (If the solicitor or proxy holder is a committee: A statement signed and verified by each member as to the amount and source of any consideration paid or to be paid to such member in connection with the case other than by way of dividend on each members claim is attached).

Dated: __________.

__________________________________________________

Signature

__________________________________________________

Address

(Jurat)

(Attachments)