B27 (Official Form27) (12/09) United States Bankruptcy Court _______________ District Of _______________ In re ____________________________, Debtor Case No. ___________________ Chapter ____ 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. Creditor’s Name:________________________________ 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. Repayment terms (if fixed rate): $_______ per month for _______ months 5. 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.) Debtor’s Schedule I and J Entries Debtor’s Income and Expenses as Stated on Reaffirmation Agreement 7A. Total monthly income from $________ Schedule I, line 16 7B. Monthly income from all $________ sources after payroll deductions 8A. Total monthly expenses from Schedule J, line 18 8B. Monthly expenses 9A. Total monthly payments on $________ reaffirmed debts not listed on Schedule J $_______ $________ 9B. Total monthly payments on $________ reaffirmed debts not included in monthly expenses 10B. Net monthly income $________ (Subtract sum of lines 8B and 9B from line 7B. If total is less than zero, put the number in brackets.) American LegalNet, Inc. www.FormsWorkFlow.com B27 (Official Form27) (12/09) Page 2 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 or12 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) _______________________________________ Signature of Joint Debtor (if applicable, and only required if line 11 or 12 is completed) Other Information G 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: _______________________________________________________________ _____________________________________________________________________________ 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’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 Reaffirmation Agreement Cover Sheet. ____________________________________ Signature ____________________________________ Print/Type Name & Signer’s Relation to Case American LegalNet, Inc. www.FormsWorkFlow.com