SOLICITATION OF PROXIES
State of _________________
County of ______________
I, __________________________________, being first sworn, on oath 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
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).