FORM F-6 Page 1 of 2 UNITED STATES BANKRUPTCY COURT FOR THE SOUTHERN DISTRICT OF WEST VIRGINIA In re Case No. Debtor(s). REAFFIRMATION AGREEMENT The undersigned debtor(s) hereby reaffirm that a debt dated the _________ day of ______________________, 20_____, owing to: _____________________________________________________________________________ in the principal amount of $_________________, which debt is secured by collateral described as: _____________________________________________________________________________, and on which monthly payments are $________________. The annual rate of interest to be paid is _______%, and the number of payments remaining are ____________. The undersigned debtor(s) do hereby assert that they understand that monthly payments must be paid on time and that failure to do so may result in default and repossession as the same is set forth in the agreement of the parties. Debtor(s) further assert that they have been advised that the agreement may be rescinded by Debtor(s) at any time prior to discharge or within sixty (60) days after it is filed with the Court, whichever occurs later, by giving notice of rescission to Creditor. Execution on this _____ day of _______________, 20___. Witness the following signatures and seals: _______________________________________(Seal) Debtor _______________________________________(Seal) Debtor _______________________________________(Seal Creditor American LegalNet, Inc. www.FormsWorkFlow.com FORM F-6 Page 2 of 2 DECLARATION OF ATTORNEY I hereby declare that I represented the Debtor(s) during the negotiation of this Agreement, and it represents a fully informed and voluntary agreement by the Debtor(s) and does not impose an undue hardship on Debtor(s) or a dependent of Debtor(s). Date: _____________________________________ Counsel for Debtor(s) American LegalNet, Inc. www.FormsWorkFlow.com