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