FOR THE __________ DISTRICT OF __________

To __________of ______ (address) and ________ of ______________ (address)

The undersigned claimant hereby authorizes you, or any one of you, as attorney in fact for the undersigned and with full power of substitution, to vote on any question that may be lawfully submitted to creditors of the debtor in the above-entitled case; (if appropriate to vote for a trustee of the estate of the debtor and for a committee of creditors; to receive dividends; and in general to perform any act not constituting the practice of law for the undersigned in all matters arising in this case.

Dated: _____________

_________________________

Signature

(If appropriate) By ______________

as ___________________________

Address:

(If executed by an individual) Acknowledged before me on ___________.

(If executed on behalf of a partnership) Acknowledged before me on __________, by __________, who says that __________ (he or she) is a member of the partnership named above and is authorized to execute this power of attorney in its behalf.

(If executed on behalf of a corporation) Acknowledged before me on ___________, by ________, who says that __________ (he or she) is ______ of the corporation named above and is authorized to execute this power of attorney in its behalf.

_________________________________

Official character.