LOCAL BANKRUPTCY FORM 4008-1.1 United States Bankruptcy Court _______________ District Of _______________ In re __________________________________________, [Set forth here all names including married, maiden, and trade names used by debtor within last 8 years.] Debtor ) ) ) ) ) Case No. ________________ ) Address ________________________________________ ) ) ________________________________________ ) Chapter ___________ ) Last four digits of Social-Security or Individual TaxPayer-Identification (ITIN) No(s).,(if any): ___________ ) ______________________________________________ ) Employer Tax-Identification (EIN) No(s).(if any): _____ ) _______________________________________________ ) American LegalNet, Inc. www.FormsWorkFlow.com COVER SHEET FOR REAFFIRMATION AGREEMENT This form must be completed in its entirety and filed within the time set under FED. R. BANKR. P. 4008. It may be filed by any party to the reaffirmation agreement. The filer also must attach a copy of the reaffirmation agreement to this cover sheet. Debtor’s Name: _____________________ Creditor’s Name: ______________________ 1. Amount of debt as of commencement of case: $____________________ 2. Amount of debt being reaffirmed: $____________________ 3. Describe collateral, if any, securing debt: ____________________________________ ________________________________________________________________________ 4. Repayment term of reaffirmation (number of months): ______________ 5. Monthly payment: Prior to reaffirmation: $___________ After reaffirmation: $______________ 6. Annual percentage rate under reaffirmation: Prior to reaffirmation: _____________ After reaffirmation: ______________ 7. Debtor's monthly income at time of reaffirmation: $___________________ 8. Income from Schedule I, line 16: $___________________ 9. Explain any difference in the amounts set out on lines 7 and 8: ___________________ ________________________________________________________________________ 10. Debtor's monthly expenses at time of reaffirmation: $___________________ (do not include the monthly expense of this reaffirmed debt) 11. Current expenditures from Schedule J, line 18: $___________________ American LegalNet, Inc. www.FormsWorkFlow.com 12. Explain any difference in the amounts set out on lines 10 and 11: ________________ ____________________________________________________________________  Check this box if the amount on Line 10 of this form exceeds the amount on Line 7 of this Form. If these expenses exceed the income, a presumption of undue hardship arises.  Check this box if the debtor was not represented by counsel during the course of negotiating this reaffirmation agreement. 13. Do the loan documents and/or sale and security agreement between the parties provide for (1) a default upon borrower filing for bankruptcy relief or becoming insolvent ____yes _____no; and/or (2) the cross-collateralization of other assets of the debtor? ____yes _____no.1 _______________________________________________________________________ FILER'S CERTIFICATION I, ______________________________, hereby certify that the attached agreement is a true and correct copy of the reaffirmation agreement between the parties identified on this Cover Sheet for Reaffirmation Agreement. Dated: _____________________ By: _________________________________ Counsel to/Agent for____________________ Attorney registration number (if applicable) Business address (or home address for pro se) Telephone number Facsimile number E-mail address DEBTOR'S CERTIFICATION (see FED. R. BANKR. PRO. 4008(b)) I, , certify that any explanation contained on lines 9 or 12 of this form is true and correct. Dated: ______________________ By: _______________________________ Signature of debtor Printed name of debtor Home address Telephone number Facsimile number E-mail address 1 If creditor does not sign this document, the information must be provided by the creditor on L.B. Form 4008-1.2. American LegalNet, Inc. www.FormsWorkFlow.com I, ) , certify that any explanation contained on lines 9 or 12 of this form is true and correct. Dated: ______________________ By: _______________________________ Signature of joint-debtor Printed name of joint-debtor Home address Telephone number Facsimile number E-mail address ATTORNEY SIGNATURE Dated: _____________________ By: _________________________________ Counsel to ___________________________ Attorney registration number (if applicable) Business address (or home address for pro se) Telephone number Facsimile number E-mail address Commentary [Source GPO 2008-2] American LegalNet, Inc. www.FormsWorkFlow.com