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Reaffirmation Agreement QUESTIONNAIRE

    Introductory Information

    Full legal name

    YesNo

    Street Address, City, State, Zip

    First Name MI Last Name

    Basic Bankruptcy Information

    As listed on bankruptcy court's docket

    YesNo
    YesNo

    Debt PRIOR to Bankruptcy

    $
    YesNo
    $

    Vehicle: Year Make Model; Home: Property Address

    Vehicle: NADA Valuation; Home: Auditor's Valuation

    YesNo
    $
    $

    Reaffirmation Agreement Details

    The Amount Reaffirmed is the entire amount that you are agreeing to pay. This may include unpaid principal, interest, and fees and costs (if any) arising on or before THIS DATE which is the date of the Disclosure Statement portion of the Reaffirmation Agreement.

    $
    FixedAdjustable
    FixedAdjustable
    $
    YesNo

    Is the creditor agreeing to provide the debtor with additional future credit in connection with this Reaffirmation Agreement? If yes, fill in the next section.

    DDescribe the credit limit, the Annual Percentage Rate that applies to future credit and any other terms on future purchases and advances using such credit:

    Debtor Finances/Expenses

    Debtor's Schedule I and J Entries

    $
    $
    $

    Debtor's Income and Expenses

    $
    $
    $
    $

    Subtract sum of lines 8B and 9B from line 7B.

    Explanation

    Explain with specificity any difference between the INCOME amounts (leave blank if no difference).

    Explain with specificity any difference between the EXPENSE amounts (leave blank if no difference).

    YesNo

    Part II - Section C Questions

    C. Sections 1 and 2 must be completed if EITHER (1) the debtor is NOT represented by an attorney during the course of negotiating this agreement OR (2) the creditor is NOT a credit union.

    1. Debtor's Present Monthly Income and Expenses

    $
    $

    DO NOT INCLUDE THIS REAFFIRMED DEBT

    $

    Subtract B from A

    $
    YesNo

    If the monthly payment on this reaffirmed debt (line D) is greater than the amount the debtor has available to pay this reaffirmed debt (line C), the debtor MUST answer "YES" (meaning: Presumption of Undue Hardship).

    Part II - Section D Question

    D. Section D must be completed if BOTH (1) the debtor is represented by an attorney during the course of negotiating this agreement OR (2) the creditor is a credit union.

    YesNo

    The debtor believes the Reaffirmation Agreement is in the debtor's financial interest and can afford to make the payments on the reaffirmed debt.

    For Internal Use Only

    For Internal Use Only

    2. Unde Hardship Question

    Income Greater

    The debtor can afford to make the payments on the reaffirmed debt because the debtor's monthly income is greater than the debtor's monthly expenses even after the debtor include in the debtor's expenses the monthly payments on all debts the debtor is reaffirming, including this one.

    For Internal Use Only

    2. Unde Hardship Question

    Income Less

    The debtor can afford to make the payments on the reaffirmed debt even though the debtor's monthly income is less than the debtor's monthly expenses after the debtor includes in the debtor's expenses the monthly payments on all debts the debtor is reaffirming, including this one, BECAUSE (complete section below):

    For Internal Use Only