LF 4008 (Rev 5/06) UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF WASHINGTON Motion for Approval of Reaffirmation Agreement Case Name__________________________ Case Number__________________ Creditor’s Name______________________________________________ I (we) the above named debtor(s) make the following statements under penalty of perjury: I (we) are not represented by an attorney in connection with this reaffirmation agreement. Nature of Security Agreement: / / Collateral is a motor vehicle and creditor appears as the lien holder on registration or certificate of title / / Signed security agreement / / Other Are payments in default? / / yes Amount owed on debt: Amount to be reaffirmed: Fair Market Value of Collateral: $____________________________ $____________________________ $____________________________ / / no I (we) believe this reaffirmation agreement is in my (our) best interest and will not impose an undue hardship on me (us) or a dependant of mine (ours) based on the income and expense I (we) have disclosed in my (our) Statement in Support of this reaffirmation, and because (provide any additional relevant reasons the court should consider): Therefore, I (we) ask the court for an order approving this reaffirmation agreement. Date:_________________ _______________________________________________ Debtor Mailing Address:_________________________________ _______________________________________________ Daytime Telephone #______________________________ _______________________________________________ Joint Debtor (if any) Mailing Address:_________________________________ _______________________________________________ Daytime Telephone #______________________________ American LegalNet, Inc. www.FormsWorkflow.com