Form 240a - Reaffirmation Agreement (
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Form 240A - Reaffirmation Agreement (1/07)
G Presumption of Undue Hardship
G No Presumption of Undue Hardship
(Check box as directed in Part D: Debtor’s Statement
in Support of Reaffirmation Agreement.)
UNITED STATES BANKRUPTCY COURT
____________________District of___________________
In re ____________________________,
Case No.__________________
Debtor
Chapter________________
REAFFIRMATION AGREEMENT
[Indicate all documents included in this filing by checking each applicable box.]
G Part A: Disclosures, Instructions, and
G Part D: Debtor’s Statement in
Notice to Debtor (pages 1 - 5)
Support of Reaffirmation Agreement
G Part B: Reaffirmation Agreement
G Part E: Motion for Court Approval
G Part C: Certification by Debtor’s Attorney
[Note: Complete Part E only if debtor was not represented by an attorney during
the course of negotiating this agreement. Note also: If you complete Part E, you must
prepare and file Form 240B - Order on Reaffirmation Agreement.]
Name of Creditor:______________________________________________
G [Check this box if] Creditor is a Credit Union as defined in §19(b)(1)(a)(iv) of the
Federal Reserve Act
PART A: DISCLOSURE STATEMENT, INSTRUCTIONS AND NOTICE TO DEBTOR
1.
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
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.
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