Fill and Sign the Bankruptcy Court Miscellaneous Fee United States Courts Form

UNITED STATES BANKRUPTCY COURT DISTRICT OF HAWAII Debtor’s Name: ) ) Case No. ) ) Chapter ) Creditor’s Name and Address: ) ) ) ) ) ) REAFFIRMATION AGREEMENT Instructions:1)Attach a copy of all court judgments, security agreements, and evidence of their perfection, concerning this debt.2)File all the documents by mailing them or delivering them to the Clerk at: United States Bankruptcy CourtDistrict of Hawaii1132 Bishop Street, Suite 250LHonolulu, HI 96813. 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 agreedamounts. 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 within60 days after this agreement is filed with the court, whichever is later, by notifying the creditor that the agreement iscanceled.You are not required to enter into this agreement by any law. It is not required by the Bankruptcy Code, by anyother 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 agreement. However, if you do not sign this agreement and arelater unwilling or unable to pay the full amount, the creditor will not be able to collect it from you. The creditor alsowill 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, you may have a right to redeem the property and eliminate thelien by making a single payment to the creditor equal to the current value of the property, as agreed by the parties ordetermined by the court .This agreement is not valid or binding unless it is filed with the clerk of the bankruptcy court. If you were notrepresented by an attorney during the negotiation of this reaffirmation agreement, the agreement cannot be enforcedby the creditor unless the agreement has been approved by the bankruptcy court. (Court approval is not required ifthis is a consumer debt secured by a mortgage or other lien on your real estate.) If court approval is required, youmust submit to the court an additional document “Motion to Approve Reaffirmation Agreement; Order” availablefrom the Clerk’s office. Upon review, the request to approve the reaffirmation agreement will be granted, denied, orscheduled for hearing for further consideration .LBF 4008-1 rev. 7/99 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 thecollection 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: 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 any): 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 SECURITY / COLLATERAL (IF ANY)Description of collateral (if applicable, list manufacturer, year and model): Value: $ Basis or source for valuation: .Current location and use of collateral: .Expected future use of collateral: .Check applicable boxes: Any lien described herein is valid and perfected. This agreement is part of a settlement of a dispute regarding the dischargeability of this debt under § 523 of the Bankruptcy Code or any other dispute. The nature of the 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, not including any payment due under thisagreement or any debt to be discharged in this bankruptcy case: $ .I believe this agreement will will not impose an undue hardship on me and my dependents. 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 § 722 of the Bankruptcy Code. I chose not to redeem because: I was was not represented by an attorney during negotiations of this agreement. CERTIFICATION OF ATTACHMENTS Any documents which created and perfected the security interest or lien are are not attached. If not attached, the documents 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 Debtor; (2) this agreement does not impose an undue hardship on Debtor or any dependent of Debtor; and (3) I have fully advised Debtor ofthe legal effect and consequences of this agreement and any default under this agreement.________________________________ Date: __________________________________(Signature of Debtor’s Attorney, if any) LBF 4008-1 rev. 7/99