Fill and Sign the As a Result of This Agreement the Creditor May Be Able to Take Your Property or Wages If You Do Not Pay the Agreed Form

Form B240 3/99REAFFIRMATION AGREEMENT UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF PENNSYLVANIA Bankruptcy Case No. Debtor's Name Chapter Creditor's Name and Address Instructions 1) Attach a copy of all court judgments, security agreemen ts, and evidence of their perfection. 2) File all the documents by mailing them or deliverin g them to the Clerk of the Bankruptcy Court. NOTICE TO DEBTOR: This agreement gives up the protection of your bankruptcy discharge for this debt. As a result of this agreement, the creditor may be able to take your property or wages if you do not pay the agreed amounts. The creditor may also act to collect the debt in other ways. You may rescind (cancel) this agreement at any time before the bankruptcy court enters a discharge order or within 60 days after this agreement is filed with the court, whichever is later, by notifying the creditor that the agreement is canceled. You are not required to enter into this agreement by any law. It is not required by the Bankruptcy Code, by any other law, or by any contract (except another reaffirmation agreement made in accordance with Bankruptcy Code § 524(c)). You are allowed to pay this debt without signing this agr eement. However, if you do not sign this agreement and are later unwilling or unable to pay the full amount, the cre ditor will not be able to collect it from you. The creditor also will not be allowed to take your property to pay the debt unless the creditor has a lien on that property. If the creditor has a lien on your personal property, y ou may have a right to redeem the property and eliminate the lien by making a single payment to the creditor equal to the current value of the property, as agreed by the parti es or determined by the court. This agreement is not valid or binding unless it is fil ed with clerk of the bankruptcy court. If you were not represented by an attorney during the negotiation of this reaffirmation agreement, the agreement cannot be enforced by the creditor unless 1) yo u have attended a reaffirmation hearing in the bankruptcy court, and 2) the agreement has been approved by the bankruptcy court. (Court approval is not required if this is a consu mer debt secured by a mortgage or other lien on your real estate.) Form B240 cont., 2 REAFFIRMATION AGREEMENT The debtor and creditor named above agree to reaffirm the debt described in this agreement as follows. THE DEBT Total Amount of Debt When Case was Filed $ _____________________ Total Amount of Debt Reaffirmed $ _____________________ Above total includes the following: Interest Accrued to Date of Agreement $ _____________________ Attorney Fees $ _____________________ Late Fees $ _____________________ Other Expenses or Costs Relating to the Collection of this Debt (Describe) $ __________________ ___ Annual Percentage Rate (APR) __________________ % Amount of Monthly Payment $ _____________________ Date Payments Start _______________________ Total Number of Payments to be made _______________________ Total of Payments if paid according to schedule _______________________ Date Any Lien Is to Be Released if paid according to schedule __________________ The debtor agrees that any and all remedies available to the creditor under the security agreement remain available. All additional Terms Agreed to by the Parties (if an y): _______________________________________________________________________________________________ _______________________________________________________________________________________________ Form B21 cont., 3 Payments on this debt were were not in default on the date on which this bankruptcy case was filed. This agreement differs from the original agreement with the creditor as follows: _______________________________________________________________________________________________ _______________________________________________________________________________________________ CREDITOR'S STATEMENT CONCERNING AGREEMENT AND SECUR ITY/COLLATERAL (IF ANY) Description of Collateral. If applicable, list manufacturer, year and model. ____________________________________ _______________________________________________________________________________________________ Value $ _________________________ Basis or Source for Valuation _________________________ Current Location and Use of Collatera l_________________________ Expected Future Use of Collateral _________________________ Check Applicable Boxes: o Any lien described herein is valid and perfected. o This agreement is part of a settlement of a dispute re garding the dischargeability of this debt under section 523 of the Bankruptcy Code (11 U.S.C. § 523) or any other dispute. T he nature of dispute is ______________________ ___________________________________________________________________________________________ DEBTOR'S STATEMENT OF EFFECT OF AGREEMENT ON DEBTOR'S FINANCES My Monthly Income (take home pay plus any other income received) is $ __________________. My current monthly expenses total $ ____________ _ , not including any payment due under this agreement o r any debt to be discharged in this bankruptcy case. I believe this agreement will will not im pose an undue hardship on me or my dependents. Form B21 cont., 4 DEBTOR'S STATEMENT CONCERNING DECISION TO REAFFIRM I agreed to reaffirm this debt because ___________________________________________________________________ _________________________________________________________________________________________________ I believe this agreement is in my best interest because _____________________________________________________ __________________________________________________________________________________________________________ I considered did not consider] redeeming the collateral under section 722 of the Bankruptcy Code (11 U. S.C. § 722). 1 chose not to redeem because__________________________________________________________________________ __________________________________________________________________________________________________________ I was was not represented by an attorney durin g negotiations on this agreement. CERTIFICATION OF ATTACHMENTS Any documents which created and perfected the security interest or lien are are not attached. [If documents are not attached]: The documents which created and perfected the security int erest or lien are not attached because ________________________________________________________________________________________________ __________________________________________________________________________________________________________ SIGNATURES ____________________________ ___________________________ (Signature of Debtor) (Name of Creditor) Date _______________________ ___________________________________________ (Signature of Creditor Representative) ____________________________ ______________________________ (Signature of Joint Debtor) Date Date _______________________ CERTIFICATION BY DEBTOR'S ATTORNEY ( IF ANY) I hereby certify that 1) this agreement represents a fully informed and voluntary agreement by the debtor(s); 2) this agreement does not impose a hardship on the debtor or any dependent of the debtor; and 3) 1 have fully advised the debtor of the legal effect and consequences of this agreeme nt and any default under this agreement. ___________________________________ _________________________ (Signature of Debtor's Attorney, if any) Date Name and Address