OFFICIAL LOCAL FORM 6 UNITED STATES BANKRUPTCY COURT DISTRICT OF MASSACHUSETTS In re Case No. Chapter Debtor REAFFIRMATION AGREEMENT COVER SHEET This form must be completed in its entirety and filed, with the reaffirmation agreement attached, within the time set under Rule 4008. It may be filed by any party to the reaffirmation agreement. 1. 2. Amount of the debt subject to this reaffirmation agreement: $________ on the date of bankruptcy $________ to be paid under reaffirmation agreement 3. Annual percentage rate of interest: ______% prior to bankruptcy ______% under reaffirmation agreement (____ Fixed Rate ____ Adjustable Rate) 4. 5. Repayment terms (if fixed rate): $___________ per month for _______ months Collateral, if any, securing the debt: Current market value: $___________________ Description: _________________________________________________________ 6. Does the creditor assert that the debt is nondischargeable? ___Yes ___ No (If yes, attach a declaration setting forth the nature of the debt and basis for the contention that the debt is nondischargeable.) American LegalNet, Inc. www.FormsWorkFlow.com 7A. Total monthly income from Schedule I, line 16 8A. Total monthly expenses from Schedule J, line 16 9A. Total monthly payment on reaffirmed debts not listed on Schedule J $______ $______ on Reaffirmation Agreement 7B. Monthly income from $_______ all sources after payroll deductions 8B. Monthly expenses $_______ $______ 9B. Total monthly payments on reaffirmed debts not included in monthly expenses 10 B. Net monthly income (Subtract sum of lines 8B and 9B from line 7B. If total is less than zero, put the number in brackets. $_______ $_______ 11. Explain with specificity any difference between the income amounts (7A and 7B): ___________________________________________________________________ ___________________________________________________________________ 12. Explain with specificity any difference between the expense amounts (8A and 8B): ___________________________________________________________________ ___________________________________________________________________ If line 11 or 12 is completed, the undersigned debtor, and joint debtor if applicable, certifies that any explanation contained on those lines is true and correct. ________________________________ Signature of Debtor (only required if line 11 or 12 is completed.) Other Information _______________________________ Signature of Joint Debtor (if applicable, and line 11 or 12 is completed) [ ] Check this box if the total on line 10B is less than zero. If that number is less than zero, a presumption of undue hardship arises (unless the creditor is a credit union) and you must explain with specificity the sources of funds available to the Debtor to make the monthly payments on the reaffirmed debt: ____________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com _________________________________________________________________________________ Was debtor represented by counsel during the course of negotiating this reaffirmation agreement? _____Yes ______No If debtor was represented by counsel during the course of negotiating this reaffirmation agreement, has counsel executed a certification (affidavit or declaration) in support of the reaffirmation agreement? _____Yes ______No FILER I hereby certify that the attached agreement is a true and correct copy of the reaffirmation agreement between the parties identified on this Reaffirmation Agreement Cover Sheet. _______________________________________________ Signature _______________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com B240A (Form B240A) (04/10) Check one. Presumption of Undue Hardship No Presumption of Undue Hardship See Debtor's Statement in Support of Reaffirmation, Part II below, to determine which box to check. UNITED STATES BANKRUPTCY COURT __________ District of __________ In re Debtor , Case No. Chapter REAFFIRMATION DOCUMENTS Name of Creditor: ______________________________________ Check this box if Creditor is a Credit Union PART I. REAFFIRMATION AGREEMENT Reaffirming a debt is a serious financial decision. Before entering into this Reaffirmation Agreement, you must review the important disclosures, instructions, and definitions found in Part V of this form. A. Brief description of the original agreement being reaffirmed: _______________________________ For example, auto loan B. AMOUNT REAFFIRMED: $___________________________ The Amount Reaffirmed is the entire amount that you are agreeing to pay. This may include unpaid principal, interest, and fees and costs (if any) arising on or before _________________, which is the date of the Disclosure Statement portion of this form (Part V). See the definition of "Amount Reaffirmed" in Part V, Section C below. C. The ANNUAL PERCENTAGE RATE applicable to the Amount Reaffirmed is _________%. See definition of "Annual Percentage Rate" in Part V, Section C below. This is a (check one) Fixed rate Variable rate If the loan has a variable rate, the future interest rate may increase or decrease from the Annual Percentage Rate disclosed here. American LegalNet, Inc. www.FormsWorkFlow.com B240A, Reaffirmation Documents Page 2 D. Reaffirmation Agreement Repayment Terms (check and complete one): $________ per month for ________ months starting on____________. Describe repayment terms, including whether future payment amount(s) may be different from the initial payment amount. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ E. Describe the collateral, if any, securing the debt: Description: Current Market Value ____________________________ $___________________________ F. Did the debt that is being reaffirmed arise from the purchase of the collateral described above? Yes. What was the purchase price for the collateral? No. What was the amount of the original loan? $___________________ $___________________ G. Specify the changes made by this Reaffirmation Agreement to the most recent credit terms on the reaffirmed debt and any related agreement: Terms as of the Date of Bankruptcy Balance due (including fees and costs) Annual Percentage Rate Monthly Payment H. Terms After Reaffirmation $__________ __________% $__________ $_________ _________% $___