Fill in this information to identify your case: Debtor 1 Debtor 2 __________________________________________________________________ First Name Middle Name Last Name ________________________________________________________________ Middle Name Last Name (Spouse, if filing) First Name United States Bankruptcy Court for the: ______________________ District of __________ (State) Case number (If known) ___________________________________________ CSD 1226 Cover Sheet for Reaffirmation Agreement 12/15 Anyone who is a party to a reaffirmation agreement may fill out and file this form. Fill it out completely, attach it to the reaffirmation agreement, and file the documents within the time set under Bankruptcy Rule 4008. Part 1: Explain the Repayment Terms of the Reaffirmation Agreement 1. Who is the creditor? __________________________________________________________________________________________________________ Name of the creditor 2. How much is the debt? On the date that the bankruptcy case is filed $__________________ To be paid under the reaffirmation agreement $__________________ $________ per month for ______ months (if fixed interest rate) 3. What is the Annual Percentage Rate (APR) of interest? (See Bankruptcy Code § 524(k)(3)(E).) 4. Does collateral secure the debt? Before the bankruptcy case was filed __________________% Under the reaffirmation agreement __________________% Fixed rate Adjustable rate No Yes. Describe the collateral. Current market value ________________________________________________________________________ $__________________ 5. Does the creditor assert that the debt is nondischargeable? No Yes. Attach an explanation of the nature of the debt and the basis for contending that the debt is nondischargeable. Income and expenses reported on Schedules I and J Income and expenses stated on the reaffirmation agreement 6. Using information from Schedule I: Your Income (Official Form 106I) and 6a. Combined monthly income from $ _____________ 6e. Monthly income from all sources $ ______________ Schedule J: Your line 12 of Schedule I after payroll deductions Expenses (Official Form 106J), fill in the amounts. 6b. Monthly expenses from line 22c of ­ $ ___________ Schedule J 6c. Monthly payments on all reaffirmed debts not listed on Schedule J 6d. Scheduled net monthly income Subtract lines 6b and 6c from 6a. If the total is less than 0, put the number in brackets. 6f. Monthly expenses ­ ­ $ ______________ ­ $ ___________ 6g. Monthly payments on all reaffirmed debts not included in monthly expenses 6h. Present net monthly income Subtract lines 6f and 6g from 6e. If the total is less than 0, put the number in brackets. $ ______________ $ ____________ $ ______________ CSD 1226 Cover Sheet for Reaffirmation Agreement American LegalNet, Inc. www.FormsWorkFlow.com page 1 Debtor 1 _______________________________________________________ First Name Middle Name Last Name Case number (if known)_____________________________________ 7. Are the income amounts on lines 6a and 6e different? No Yes. Explain why they are different and complete line 10._____________________________________________ ______________________________________________________________________________________ 8. Are the expense amounts on lines 6b and 6f different? No Yes. Explain why they are different and complete line 10.______________________________________________ ______________________________________________________________________________________ 9. Is the net monthly income in line 6h less than 0? No Yes. A presumption of hardship arises (unless the creditor is a credit union). Explain how the debtor will make monthly payments on the reaffirmed debt and pay other living expenses. Complete line 10. ______________________________________________________________________________________ ______________________________________________________________________________________ 10. Debtor's certification about lines 7-9 If any answer on lines 7-9 is Yes, the debtor must sign here. If all the answers on lines 7-9 are No, go to line 11. I certify that each explanation on lines 7-9 is true and correct. ________________________________________ ___________________________ Signature of Debtor 1 Signature of Debtor 2 (Spouse Only in a Joint Case) 11. Did an attorney represent the debtor in negotiating the reaffirmation agreement? No Yes. Has the attorney executed a declaration or an affidavit to support the reaffirmation agreement? No Yes Part 2: Sign Here Whoever fills out this form I certify that the attached agreement is a true and correct copy of the reaffirmation agreement between the must sign here. parties identified on this Cover Sheet for Reaffirmation Agreement. _____________________________________________________________ Signature Date _________________ MM / DD / YYYY _____________________________________________________________________ Printed Name Check one: Debtor or Debtor's Attorney Creditor or Creditor's Attorney Cover Sheet for Reaffirmation Agreement page 2 American LegalNet, Inc. www.FormsWorkFlow.com CSD 1226 CSD 1226 [12/01/15] Name, Address, Telephone No. & I.D. No. UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF CALIFORNIA 325 West F Street, San Diego, California 92101-6991 In Re BANKRUPTCY NO. Debtor. REAFFIRMATION AGREEMENT Presumption of Undue Hardship No Presumption of Undue Hardship (Check box as directed in Part D: Debtor's Statement in Support of Reaffirmation Agreement.) Name of Creditor: [Check this box if] Creditor is a Credit Union as defined in § 19(b)(1)(a)(iv) of the Federal Reserve Act. PART A: 1. DISCLOSURE STATEMENT, INSTRUCTIONS AND NOTICE TO DEBTOR DISCLOSURE STATEMENT Before Agreeing to Reaffirm a Debt, Review These Important Disclosures: SUMMARY OF REAFFIRMATION AGREEMENT This Summary is made pursuant to the requirements of the Bankruptcy Code. AMOUNT REAFFIRMED The amount of debt you have agreed to reaffirm: $ The amount of debt you have agreed to reaffirm includes all fees and costs (if any) that have accrued as of the date of this disclosure. Your credit agreement may obligate you to pay additional amounts which may come due after the date of this disclosure. Consult your credit agreement. ANNUAL PERCENTAGE RATE [The annual percentage rate can be disclosed in different ways, depending on the type of debt.] a. If the debt is an extension of "credit" under an "open end credit plan," as those terms are defined in § 103 of the Truth in Lending Act, such as a credit car