UNITED STATES BANKRUPTCY COURT DISTRICT OF OREGON In re Debtor(s) ) ) ) ) ) ) ) ) Case No. ________________ REAFFIRMATION AGREEMENT COVER SHEET [NOTE: YOU MUST COMPLETE ALL BLANKS ON THIS FORM. IF THIS DOCUMENT IS DEFICIENT IN ANY WAY, IT WILL BE RETURNED AND WILL NOT BE CONSIDERED BY THE COURT!] 1. CREDITOR NAME: _______________________________________________________________________________________ 2. CREDITOR ADDRESS: ____________________________________________________________________________________ 3. IS THIS A CONSUMER DEBT SECURED BY REAL PROPERTY? [NOTE: Real property is only LAND, plus any permanent structures.] YES NO 4. PROPOSED: PRINCIPAL: $____________ INTEREST RATE: ______% per annum MONTHLY PAYMENT: $____________ 5. INSERT DESCRIPTION OF ITEM(S) AS LISTED IN PT. A.1.d. OF THE AGREEMENT (If REAL property insert address; or if no items(s) listed, so indicate): __________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ 6. PRESENT MARKET VALUE OF SECURITY: $_________________________________________________________________ 7. MAXIMUM MONTHLY PAYMENT REQUIRED UNDER THIS REAFFIRMATION AGREEMENT: $___________ 8.a. 9.a. 10.a. 11.a. TOTAL MONTHLY INCOME FROM SCHEDULE I: $___________ b. CURRENT MONTHLY INCOME FROM PART D. OF REAFFIRMATION AGREEMENT: $___________ TOTAL MONTHLY EXPENSES FROM SCHEDULE J: $___________ b. CURRENT MONTHLY EXPENSES FROM PART D. OF REAFFIRMATION AGREEMENT: $___________ TOTAL MONTHLY PAYMENTS ON REAFFIRMED DEBTS NOT LISTED ON SCHEDULE J: b. MONTHLY PAYMENT FOR THIS REAFFIRMATION AGREEMENT FROM PT. 7 ABOVE: $___________ $___________ b. NET MONTHLY INCOME (Calculate only using NET MONTHLY INCOME (Calculate only figures in this column by taking the total income using figures in this column by taking the listed in pt. 8.b. MINUS the total of BOTH the Schedule I Total Monthly Income in pt. 8.a. Expenses listed in pt. 9.b. AND the payment MINUS the total of BOTH the Monthly Expenses in pt. 9.a. AND in pt. 10.a. listed in pt. 10.b. NOTE: If this total is less NOTE: If this total is less than zero, put than zero, put the number in brackets): 11.b. $___________ the number in brackets): $___________ 12. [This MUST be answered unless (a) Creditor is a Credit Union, or (b) you accurately answered “YES” in pt. 3] IS UNDUE HARDSHIP PRESUMED? (NOTE: Mark “YES” if amount in pt. 11.b. is less than zero): YES NO 13. EXPLAIN: (1) Any difference between the income and expense amounts on Schedules I and J (in pts. 8.a. & 9.a.) and those in the Reaffirmation Agreement (in pts. 8.b. & 9.b.) AND (2) any additional information beyond any in PART E about either why the Agreement is in the debtor’s best interest or why the debtor(s) can make the payment despite the presumption of undue hardship: I, THE UNDERSIGNED, CERTIFY UNDER PENALTY OF PERJURY THAT: (1) The original Reaffirmation Agreement (e.g., using Local Form #718.5) IS ATTACHED; (2) the information above is identical to that found in the Schedules and Reaffirmation Agreement; AND (3) all of the above information is true and correct. 718.05 (8/8/08) ______________________________________________________ Signature ____________________________________________________ Print/Type Name & Signer’s Relation to Case American LegalNet, Inc. www.FormsWorkflow.com