Official Form 427 - Cover Sheet For Reaffirmation Agreement - 2015
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1
2Fill in this information to identify your case:
Debtor 1
__________________________________________________________________
First Name
Middle Name
Last Name
Debtor 2
________________________________________________________________
(Spouse, if filing)
First Name
Middle Name
Last Name
__________
__________ District of __________
__________
United States Bankruptcy Court for the:
District of
Case number
___________________________________________
(If known)
Official Form 427
Cover Sheet for Reaffirmation Agreement
12/15
Anyone who is a party to a reaffirmation agreement may fill out and file this form. Fill it out completely, attach it to the reaffirmation agreement,
and file the documents within the time set under Bankruptcy Rule 4008.
Part 1:
Explain the Repayment Terms of the Reaffirmation Agreement
1. Who is the creditor?
__________________________________________________________________________________________________________
Name of the creditor
2. How much is the debt?
On the date that the bankruptcy case is filed
$__________________
To be paid under the reaffirmation agreement $__________________
$________ per month for ______ months (if fixed interest rate)
3. What is the Annual
Before the bankruptcy case was filed __________________%
Percentage Rate (APR)
of interest? (See
Bankruptcy Code
Under the reaffirmation agreement
__________________%
Fixed rate
§ 524(k)(3)(E).)
Adjustable rate
4. Does collateral secure
No
the debt?
Yes. Describe the collateral.
________________________________________________________________________
Current market value
$__________________
5. Does the creditor assert
No
that the debt is
Yes. Attach an explanation of the nature of the debt and the basis for contending that the debt is nondischargeable.
nondischargeable?
6. Using information from
Income and expenses reported on Schedules I and J
Income and expenses stated on the reaffirmation agreement
Schedule I: Your Income
(Official Form 106I) and
6a. Combined monthly income from
$ _____________ 6e. Monthly income from all sources
$ ______________
Schedule J: Your
line 12 of Schedule I
after payroll deductions
Expenses (Official Form
106J), fill in the amounts.
6b. Monthly expenses from line 22c of
6f. Monthly expenses
–
–
$ ___________
$ ______________
Schedule J
6c. Monthly payments on all
6g. Monthly payments on all
–
–
$ ___________
$ ______________
reaffirmed debts not listed on
reaffirmed debts not included in
Schedule J
monthly expenses
6d. Scheduled net monthly income
$ ____________
6h. Present net monthly income
$ ______________
Subtract lines 6b and 6c from 6a.
Subtract lines 6f and 6g from 6e.
If the total is less than 0, put the
If the total is less than 0, put the
number in brackets.
number in brackets.
Official Form 427
Cover Sheet for Reaffirmation Agreement
page 1
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