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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
ACKNOWLEDGEMENT BY NOTARY PUBLIC
State of ________)
) SS.:
County of________)
On ________, before me, ________, [NAME OF NOTARY], personally appeared ________, [NAME OF PERSON(S) INVOLVED], who proved to me on the basis of satisfactory evidence to be the person(s) whose names(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies) and that by his/her/their signatures on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under the PENALTY OF PERJURY under the laws of the State of _________ that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
[signature]
Name of Notary
Notary Public
My Commission Expires
[SEAL]