Fill and Sign the This Agreement Gives Up the Protection of Your Bankruptcy Discharge for This Debt Form

Form B240 3/99 REAFFIRMATION AGREEMENT UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF PENNSYLVANIA Bankruptcy Case No. Debtor's Name Chapter Creditor's Name and Address Instructions 1) Attach a copy of all court judgments, security agreements, and evidence \ of their perfection. 2) File all the documents by mailing them or delivering them to the Cle\ rk of the Bankruptcy Court. 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 pro\ perty or wages if you do not pay the agreed amounts. The creditor may also act to collect the debt in other ways. You may rescind (cancel) this agreement at any time before the bankrup\ tcy court enters a discharge order or within 60 days after this agreement is filed with the court, whichever is later\ , by notifying the creditor that the agreement is canceled. You are not required to enter into this agreement by any law. It is not required by the Bankruptcy Code, by any other law, or by any contract (except another reaffirmation agreement m\ ade 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 are later unwilling or unable to pay the full amount, the creditor will not \ be able to collect it from you. The creditor also will not be allowed to take your property to pay the debt unless the cre\ ditor has a lien on that property. If the creditor has a lien on your personal property, you may have a rig\ ht to redeem the property and eliminate the lien by making a single payment to the creditor equal to the current val\ ue of the property, as agreed by the parties or determined by the court. This agreement is not valid or binding unless it is filed with clerk of \ the bankruptcy court. If you were not represented by an attorney during the negotiation of this reaff\ irmation agreement, the agreement cannot be enforced by the creditor unless 1) you have attende\ d a reaffirmation hearing in the bankruptcy court, and 2) the agreement has been approved\ by the bankruptcy court. (Court approval is not required if this is a consumer debt secur\ ed by a mortgage or other lien on your real estate.) Form B240 cont., 2 Total Amount of Debt When Case was Filed $ ___________ Form B21 cont., 3 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 Collatera l__________ Expected Future Use of Collateral __________ Check Applicable Boxes: o Any lien described herein is valid and perfected. o This agreement is part of a settlement of a dispute regarding the dischargeability of this debt under section 523 of the Bankruptcy Code (11 U.S.C. § 523) or any other dispute. The nat\ ure of 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 total $ __ _ , not including any payment due under this agreement or any debt to be discharged in this bankruptcy case. I believe this agreement will will not impose an undue hardship on me or my dependents. Form B21 cont., 4 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 section 722 of the Bank\ ruptcy Code (11 U.S.C. § 722). 1 chose not to redeem because_______________\ ______________ _____________________________\ _________________ I was was not represented by an attorney during negotiations on this agreement. CERTIFICATION OF ATTACHMENTS Any documents which created and perfected the security interest or lien \ are are not attached. [If documents are not attached]: The documents which created and perfected the security interest or lien 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 the debtor(s); 2) this agreement does not impose a hardship on the debtor or any dependent of t\ he debtor; and 3) 1 have fully advised the debtor of the legal effect and consequences of this agreement and any default u\ nder this agreement. _________________ _____________ (Signature of Debtor's Attorney, if any) Date