Fill and Sign the Reaffirmation Agreement Form

IN THE UNITED STATES BANKRUPTCY COURT FOR THE NORTHERN DISTRICT OF MISSISSIPPI IN RE:       CASE NO:       REAFFIRMATION AGREEMENT Debtor(s) and Creditor hereby enter into this reaffirmation agreement as to the herein described debt, which is dischargeable under Chapter 7 of Title 11 of the United States Code. NAME & ADDRESS OF CREDITOR SECURITY REAFFIRMATION AMOUNT PERIODIC PAYMENT                                                                         In consideration of the new promise by debtor(s) hereby reaffirmed to pay said debt and the retention by debtor(s) of the subject security, this agreement is hereby made after notice to the Debtor(s) as follows: NOTICE TO DEBTOR(S) THIS AGREEMENT IS NOT REQUIRED UNDER THE BANKRUPTCY CODE, UNDER NONBANKRTUPCY LAW OR UNDER ANY OTHER AGREEMENT WHICH IS NOT IN ACCORDANCE WITH THE PROVISIONS OF 11 U.S.C. § 524 (C). THIS AGREEMENT MAY BE RESCINDED AT ANY TIME PRIOR TO DISCHARGE OR WIHTIN 60 DAYS AFTER SUCH AGREEMENT IS FILED WITH THE COURT, WHICHEVER OCCURS LATER, BY GIVING NOTICE OF RESCISSION TO THE AFOREMENTIONED SECURED CREDITOR. DECLARATION OF ATTORNEY I,       , attorney for Debtor(s), do hereby declare of affirm that I represented the Debtor(s) during the course of negotiating this reaffirmation agreement and that: 1) I fully advised the Debtor(s) of the legal effect and consequences of entering into this reaffirmation agreement and of the legal effect and consequences of any default under this reaffirmation agreement. 2) This reaffirmation agreement represents a fully informed and voluntary agreement by the Debtor(s) and does not impose an undue hardship on the Debtor(s) or a dependent of the Debtor(s). MADE this the       Day of       ,       . _______________________________ ATTORNEY FOR DEBTOR(S) ________________________________ _______________________________ DEBTOR CREDITOR ________________________________ DEBTOR ATTACHED IS A CLEAR COPY OF EACH PERTINENET UCC OR OTHER SECURITY DOCUMENT FORMING THE BASIS OF THIS REAFFIRMATION AGREEMENT. ________________________________ ATTORNEY FOR DEBTOR(S)