Bankruptcy Explanation Form

BANKRUPTCY EXPLANATION FORM

This Bankruptcy Explanation Form is submitted by Debtor Name: and delivered to Recipient Name: for the purpose of providing a written statement of the circumstances, facts and current status relating to the bankruptcy proceeding identified below.

RECITALS

WHEREAS, Debtor has filed or been named in a bankruptcy case and the Recipient requires a contemporaneous explanation of the factual circumstances surrounding the filing; and

WHEREAS, Debtor represents that the information provided in this form is provided under penalty of perjury to support evaluation of creditworthiness, claim resolution, or other permissible business purposes identified by Recipient; and

WHEREAS, Recipient agrees to rely on the statements and authorizations contained herein in making determinations related to rights, obligations, or claims between the parties.

NOW THEREFORE, in consideration of the mutual promises contained herein, the parties agree as follows:

1. DEFINITIONS

For purposes of this Form, "Debtor" means the individual or entity identified as Debtor Name above; "Recipient" means the individual or entity identified as Recipient Name above; "Bankruptcy Case" means the case filed in the court identified below.

2. BANKRUPTCY CASE INFORMATION

Court Name:

Case Number:    Chapter Filed: Chapter 7 Chapter 11 Chapter 13 Other:

Filing Date:    Discharge or Dismissal Date (if any):

3. STATEMENT OF FACTS

Provide a clear, chronological explanation of the principal events, transactions and circumstances that led to the bankruptcy filing, including any business interruptions, medical events, divorce, job loss, or other material causes. Attach additional pages if necessary.

Were any of the debts listed in the bankruptcy incurred for business activities? Yes No If yes, explain:

4. FINANCIAL INFORMATION AT TIME OF FILING

5. ACTIONS TAKEN SINCE FILING

Describe actions taken to resolve creditor claims, complete plan payments, enter reaffirmation agreements, or otherwise address obligations since the filing.

6. CURRENT FINANCIAL STATUS

Current bankruptcy status: Discharged Dismissed Pending If discharged/dismissed, date:

7. ATTACHMENTS AND DOCUMENTS

The Debtor certifies that copies of the following documents are attached or will be made available upon request: Schedules A–J, Statement of Financial Affairs, Plan (if applicable), Order of Discharge or Dismissal, and any reaffirmation agreements.

8. CERTIFICATION AND AUTHORIZATION

I, the undersigned Debtor, declare under penalty of perjury under the laws of the applicable jurisdiction that the information provided herein is true, correct and complete to the best of my knowledge. I authorize Recipient to verify the facts stated in this form, to obtain credit reports, and to request supporting documents from courts, trustees, or other third parties as reasonably necessary to verify the statements made herein.

9. NOTICES

10. GENERAL PROVISIONS

Governing Law: This Form shall be governed by and construed in accordance with the laws of the state of without regard to its conflicts of law rules.

Entire Agreement: This Form constitutes the entire written agreement between the parties with respect to the subject matter herein and supersedes all prior oral or written statements or understandings concerning the same.

Severability: If any provision of this Form is held invalid or unenforceable, the remaining provisions shall remain in full force and effect and shall be construed so as to effectuate the intent of the parties to the fullest extent permitted by law.

Amendments; Waiver; Counterparts: Any amendment or modification of this Form must be in writing and signed by both parties. No waiver shall be effective unless in writing and signed by the waiving party. This Form may be executed in counterparts, each of which shall be deemed an original.

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