Fill and Sign the Reaffirmation Coversheet Oregon Form

UNITED STATES BANKRUPTCY COURT DISTRICT OF OREGON In re ) ) Case No       ) ) REAFFIRMATION AGREEMENT ) COVERSHEET FOR DEBTOR(S) ) WITH NO ATTORNEY )       ) [NOTE : YOU MUST FULLY COMPLETE ALL ON THIS FORM AND ATTACH COPIES OF ALL DOCUMENTS REQUIRED BELOW. IF DOCUMENTS ARE DEFICIENT IN ANY WAY, THEY WILL BE RETURNED AND WILL NOT BE CONSIDERED BY THE COURT! ]            ) ) ) ) ) ) Debtor(s) ) CREDITOR NAME: CREDITOR ADDRESS: PROPOSED: PRINCIPAL: $       INTEREST RATE:       % per annum PAYMENT: $       monthly SUMMARY OF TERMS OF NEW AGREEMENT: ORIGINAL DEFAULT PROVISIONS ARE ON PAGE(S)       OF THE ATTACHED ORIGINAL AGREEMENT. DESCRIPTION OF SECURITY: (If none, so indicate) PRESENT MARKET VALUE OF SECURITY: $ A TOTAL MONTHLY INCOME @ LISTED ON SCHEDULE I: $ A TOTAL MONTHLY EXPENSES @ LISTED ON SCHEDULE J: $ I, THE UNDERSIGNED, CERTIFY EACH OF THE FOLLOWING UNDER PENALTY OF PERJURY THAT: (1) BOTH the original reaffirmation agreement AND a copy of the original written agreement between the debtor and creditor which created the debt and any security interest, and any documents incorporated by reference therein, ARE ATTACHED to this LBF #718; (2) the reaffirmation agreement controls if there are any discrepancies between it and this LBF #718; AND (3) all of the above information is true and correct.  ___________________________ Signature Print/Type Name & Signer = s Relation to Case OSB# (if atty.) TO BE COMPLETED BY CREDITOR : The original agreement WAS WAS NOT in default as of the date of the new agreement; and the new agreement DOES DOES NOT waive the default. Dated:___________________________ Creditor:_________________________________________ Title 718 (10/1/01) Date: Creditor Title: