Free LBR Form I - Rhode Island

R.I. Bankr. Form I See R.I. LBRs 3018-1 and 3020-1 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.

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: