Fill and Sign the Summary Agreement Form

UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF VIRGINIA SUMMARY OF REAFFIRMATION AGREEMENT Name of Debtor(s) [Name of Debtor and, if applicable, Joint Debtor] Case No. [Case No.] Chapter [Chapter] Instructions 1. Complete debtor’s name, bankruptcy case number and chapter above. 2. PART A – Complete each item. Both the debtor(s) and creditors must sign. 3. PART B – Must be signed by the attorney who represents the debtor(s) in bankruptcy, if any. 4. PART C – Complete only when debtor(s) not represented by attorney. 5. File the fully completed form by mailing or delivering it to the Clerk of Court at an appropriate address as follows: U.S. Bankruptcy Court, P.O. Box 19247, Alexandria, VA, 22320-0247 (Mailing) PART A – AGREEMENT Creditor’s Name and Address [Name & Complete Address of Creditor] Terms of New Agreement a) Amount Principal $       Interest Rate (APR)       monthly Payments $       b) Security (collateral) Description             Present Market Value$       Date set for Entry of Discharge [Complaint Deadline] The agreement understood is purely voluntary and that the debtor(s) may rescind the agreement at any time prior to discharge or within 60 days after such agreement is filed with the Court, whichever occurs later, by giving notice of rescission to the creditor. This agreement was entered into before the date of discharge in the above case the debtor(s) understands that this agreement is not required by the Bankruptcy Code, under or on bankruptcy law, or under any agreement not in accordance with 524(c) or the Bankruptcy Code. Date: Debtor’s Signature Creditor’s Signature Joint Debtor’s Signature, if applicable PART B – ATTORNEY’S DECLARATION This agreement represents a fully informed and voluntary agreement by the debtor(s) that does not impose an undue hardship on the debtor(s) or any dependent of the debtor(s). I have fully advised the debtor(s) of the legal effects and consequences of entering into an agreement of this kind and any default under this agreement. Attorney’s name and Address:       Name of Attorney Signature of Debtor’s Attorney       Attorney Address             City, State, and Zip Date PART C – MOTION FOR COURT APPROVAL OF AGREEMENT – complete only where debtor(s) not represented by an attorney I (we), the debtor, affirm the following to be true and correct: 1) I am not represented by an attorney in connection with this bankruptcy case. 2)My current monthly net income is $       . 3) My current monthly expense total $       , including any payment due under this agreement. 4) I believe that this agreement is in my best interest because             Date Signature of Debtor Signature of Joint Debtor, if applicable