Proxy (Subsection 102(2) and paragraphs 51(1)(e) and 66.15(3)(b) of the Act) Name and location of Creditor Name and location of person appointed by creditor to be a proxy Signed at location and date Creditor and witness Individual creditor and witness Name of Individual Creditor Name of Individual Witness Corporate creditor and witness Name of Signing Officer Corporation name Name of Corporate Witness Provide any additional information related to the form.