Form B27 - Reaffirmation Agreement Cover Sheet
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2B27 (Official Form 27) (12/09)
U
S
B
C
NITED
TATES
ANKRUPTCY
OURT
__________ District of __________
In re ____________________________,
Debtor
Case No. ___________________
Chapter ____
REAFFIRMATION AGREEMENT COVER SHEET
This form must be completed in its entirety and filed, with the reaffirmation agreement attached,
within the time set under Rule 4008. It may be filed by any party to the reaffirmation agreement.
1.
Creditor’s Name:________________________________
2.
Amount of the debt subject to this reaffirmation agreement:
$________ on the date of bankruptcy
$________ to be paid under reaffirmation agreement
3.
Annual percentage rate of interest:
______% prior to bankruptcy
______% under reaffirmation agreement ( ____ Fixed Rate ____ Adjustable Rate)
4.
Repayment terms (if fixed rate): $_______ per month for _______ months
5.
Collateral, if any, securing the debt: Current market value: $_________
Description: _____________________________________________
6.
Does the creditor assert that the debt is nondischargeable? ___Yes ___ No
(If yes, attach a declaration setting forth the nature of the debt and basis for the contention that the debt
is nondischargeable.)
Debtor’s Schedule I and J Entries
Debtor’s Income and Expenses
as Stated on Reaffirmation Agreement
7A. Total monthly income from $________
7B.
Monthly income from all
$________
Schedule I, line 16
sources after payroll deductions
8A. Total monthly expenses
$_______
8B.
Monthly expenses
$________
from Schedule J, line 18
9A. Total monthly payments on $________
9B. Total monthly payments on
$________
reaffirmed debts not listed on
reaffirmed debts not included in
Schedule J
monthly expenses
10B. Net monthly income
$________
(Subtract sum of lines 8B and 9B from
line 7B. If total is less than zero, put the
number in brackets.)
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