Fill in this information to identify your case: Debtor 1 Debtor 2 __________________________________________________________________ First Name Middle Name Last Name (Spouse, if filing) First Name ________________________________________________________________ Middle Name Last Name United States Bankruptcy Court for the: ______________________ District of __________ (State) Case number (If known) ___________________________________________ Official Form 427 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. $ ______________ $ ____________ $ ______________ Official Form 427 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 Official Form 427 Cover Sheet for Reaffirmation Agreement page 2 American LegalNet, Inc. www.FormsWorkFlow.com