Form 240a Sample - Reaffirmation Agreement (Page 2 of 10) in pdf

Official form 240A dated 1/07 must be used. If an older version is used or a non-

official form, a deficiency notice may be issued by the Court.

Form 240A - Reaffirmation Agreement (1/07)

G Presumption of Undue Hardship

One of these two check

G No Presumption of Undue Hardship

boxes must be checked,

(Check box as directed in Part D: Debtor’s Statement

using the information from

in Support of Reaffirmation Agreement.)

Part D

UNITED STATES BANKRUPTCY COURT

Debtor's name(s) required

Case number required

____________________District of___________________

In re ____________________________,

Case No.__________________

Debtor

Chapter________________

REAFFIRMATION AGREEMENT

Parts A, B, and D must

[Indicate all documents included in this filing by checking each applicable box.]

be included. Part C is

optional. Part E must

G Part A: Disclosures, Instructions, and

G Part D: Debtor’s Statement in

be filed if: this is a pro

Notice to Debtor (pages 1 - 5)

Support of Reaffirmation Agreement

se case OR the debtor's

attorney has not signed

G Part B: Reaffirmation Agreement

G Part E: Motion for Court Approval

the Declaration in part C

OR Part C has not been

G Part C: Certification by Debtor’s Attorney

filed at all. Part E is not

required however if the

[Note: Complete Part E only if debtor was not represented by an attorney during

Reaffirmation

the course of negotiating this agreement. Note also: If you complete Part E, you must

Agreement is on real

prepare and file Form 240B - Order on Reaffirmation Agreement.]

property.

Creditor's name must be here

Name of Creditor:______________________________________________

If creditor is a credit

G [Check this box if] Creditor is a Credit Union as defined in §19(b)(1)(a)(iv) of the

union, this box

Federal Reserve Act

must be checked

PART A: DISCLOSURE STATEMENT, INSTRUCTIONS AND NOTICE TO DEBTOR

DISCLOSURE STATEMENT

Before Agreeing to Reaffirm a Debt, Review These Important Disclosures:

SUMMARY OF REAFFIRMATION AGREEMENT

This Summary is made pursuant to the requirements of the Bankruptcy Code.

AMOUNT REAFFIRMED

This amount must be filled in

The amount of debt you have agreed to reaffirm:

$_________________

The amount of debt you have agreed to reaffirm includes all fees and costs (if any) that have

accrued as of the date of this disclosure. Your credit agreement may obligate you to pay additional

amounts which may come due after the date of this disclosure. Consult your credit agreement.

Form 240a Sample - Reaffirmation Agreement Page 2

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