CACB — Cover Sheet for Reaffirmation Agreement (427)

Source: https://www.cacb.uscourts.gov/sites/cacb/files/documents/forms/427.pdf

Fill 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

United States Bankruptcy Court for the: ______________________ District of __________ (State) 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 nondischargeable? Yes. Attach an explanation of the nature of the debt and the basis for contending that the debt is 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 Schedule J: Your 6a. Combined monthly income from $ _____________ 6e. Monthly income from all sources $ ______________ Expenses (Official Form line 12 of Schedule I after payroll deductions 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

Debtor 1 _______________________________________________________ Case number (if known)_____________________________________ First Name Middle Name Last Name

7. Are the income amounts No on lines 6a and 6e Yes. Explain why they are different and complete line 10._____________________________________________ different? ______________________________________________________________________________________

8. Are the expense No amounts on lines 6b Yes. Explain why they are different and complete line 10.______________________________________________ and 6f different? ______________________________________________________________________________________

9. Is the net monthly No income in line 6h less Yes. A presumption of hardship arises (unless the creditor is a credit union). than 0? Explain how the debtor will make monthly payments on the reaffirmed debt and pay other living expenses. Complete line 10. ______________________________________________________________________________________ ______________________________________________________________________________________

10. Debtor’s certification I certify that each explanation on lines 7-9 is true and correct. about lines 7-9

    If any answer on lines 7-9 is Yes, the debtor must sign here. ________________________________________ ___________________________ If all the answers on lines 7-9 Signature of Debtor 1 Signature of Debtor 2 (Spouse Only in a Joint Case) are No, go to line 11.

11. Did an attorney represent No the debtor in negotiating Yes. Has the attorney executed a declaration or an affidavit to support the reaffirmation agreement? the reaffirmation No agreement? Yes

Part 2: Sign Here

Whoever fills out this form I certify that the attached agreement is a true and correct copy of the reaffirmation agreement between the must sign here. parties identified on this Cover Sheet for Reaffirmation Agreement.

_____________________________________________________________ Date _________________
Signature MM / DD / YYYY

_____________________________________________________________________
Printed Name

Check one:
Debtor or Debtor’s Attorney
Creditor or Creditor’s Attorney

Official Form 427 Cover Sheet for Reaffirmation Agreement page 2