Sample Reaffirmation Agreement
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10SAMPLE REAFFIRMATION AGREEMENT
illustrating requirements for filing in a post-Bankruptcy Reform Act case
in the Southern District of Indiana
FILING THE REAFFIRMATION AGREEMENT:
Check that you answer the following questions correctly when the system prompts you:
Enter correct creditor name
Motion for Approval included in the PDF of the Reaffirmation Agreement? (yes or no)
Credit union? (yes or no)
Real property? (yes or no)
Undue hardship? (yes or no - take your answer from Parts C and D)
Attorney certification filed? (yes or no - only answer 'yes' if you have SIGNED part C)
DO NOT include a Proposed Order as part of the Reaffirmation Agreement - the Court
will prepare one if required.
SAMPLE REAFFIRMATION AGREEMENT
illustrating requirements for filing in a post-Bankruptcy Reform Act case
in the Southern District of Indiana
FILING THE REAFFIRMATION AGREEMENT:
Check that you answer the following questions correctly when the system prompts you:
Enter correct creditor name
Motion for Approval included in the PDF of the Reaffirmation Agreement? (yes or no)
Credit union? (yes or no)
Real property? (yes or no)
Undue hardship? (yes or no - take your answer from Parts C and D)
Attorney certification filed? (yes or no - only answer 'yes' if you have SIGNED part C)
DO NOT include a Proposed Order as part of the Reaffirmation Agreement - the Court
will prepare one if required.
Official form 240A dated 1/07 must be used. If an older version is used or a non-
official form, a deficiency notice may be issued by the Court.
Form 240A - Reaffirmation Agreement (1/07)
G Presumption of Undue Hardship
One of these two check
G No Presumption of Undue Hardship
boxes must be checked,
(Check box as directed in Part D: Debtor’s Statement
using the information from
in Support of Reaffirmation Agreement.)
Part D
UNITED STATES BANKRUPTCY COURT
Debtor's name(s) required
Case number required
____________________District of___________________
In re ____________________________,
Case No.__________________
Debtor
Chapter________________
REAFFIRMATION AGREEMENT
Parts A, B, and D must
[Indicate all documents included in this filing by checking each applicable box.]
be included. Part C is
optional. Part E must
G Part A: Disclosures, Instructions, and
G Part D: Debtor’s Statement in
be filed if: this is a pro
Notice to Debtor (pages 1 - 5)
Support of Reaffirmation Agreement
se case OR the debtor's
attorney has not signed
G Part B: Reaffirmation Agreement
G Part E: Motion for Court Approval
the Declaration in part C
OR Part C has not been
G Part C: Certification by Debtor’s Attorney
filed at all. Part E is not
required however if the
[Note: Complete Part E only if debtor was not represented by an attorney during
Reaffirmation
the course of negotiating this agreement. Note also: If you complete Part E, you must
Agreement is on real
prepare and file Form 240B - Order on Reaffirmation Agreement.]
property.
Creditor's name must be here
Name of Creditor:______________________________________________
If creditor is a credit
G [Check this box if] Creditor is a Credit Union as defined in §19(b)(1)(a)(iv) of the
union, this box
Federal Reserve Act
must be checked
PART A: DISCLOSURE STATEMENT, INSTRUCTIONS AND NOTICE TO DEBTOR
1.
DISCLOSURE STATEMENT
Before Agreeing to Reaffirm a Debt, Review These Important Disclosures:
SUMMARY OF REAFFIRMATION AGREEMENT
This Summary is made pursuant to the requirements of the Bankruptcy Code.
AMOUNT REAFFIRMED
This amount must be filled in
The amount of debt you have agreed to reaffirm:
$_________________
The amount of debt you have agreed to reaffirm includes all fees and costs (if any) that have
accrued as of the date of this disclosure. Your credit agreement may obligate you to pay additional
amounts which may come due after the date of this disclosure. Consult your credit agreement.
The percentage rate must be stated in the
appropriate section of Part A
Form 240A - Reaffirmation Agreement (Cont.)
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ANNUAL PERCENTAGE RATE
[The annual percentage rate can be disclosed in different ways, depending on the type of debt.]
a. If the debt is an extension of “credit” under an “open end credit plan,” as those terms
are defined in § 103 of the Truth in Lending Act, such as a credit card, the creditor may disclose
the annual percentage rate shown in (i) below or, to the extent this rate is not readily available or
not applicable, the simple interest rate shown in (ii) below, or both.
(i) The Annual Percentage Rate disclosed, or that would have been disclosed, to
the debtor in the most recent periodic statement prior to entering into the
reaffirmation agreement described in Part B below or, if no such periodic
statement was given to the debtor during the prior six months, the annual
percentage rate as it would have been so disclosed at the time of the disclosure
statement: ______%.
--- And/Or ---
(ii) The simple interest rate applicable to the amount reaffirmed as of the date
this disclosure statement is given to the debtor: __________%. If different
simple interest rates apply to different balances included in the amount
reaffirmed, the amount of each balance and the rate applicable to it are:
$ _________@ _________%;
$_________ @ _________%;
$_________ @ _________%.
b. If the debt is an extension of credit other than under than an open end credit plan, the
creditor may disclose the annual percentage rate shown in (I) below, or, to the extent this rate is
not readily available or not applicable, the simple interest rate shown in (ii) below, or both.
(i) The Annual Percentage Rate under §128(a)(4) of the Truth in Lending Act, as
disclosed to the debtor in the most recent disclosure statement given to the debtor
prior to entering into the reaffirmation agreement with respect to the debt or, if no
such disclosure statement was given to the debtor, the annual percentage rate as it
would have been so disclosed: _________%.
--- And/Or ---
(ii) The simple interest rate applicable to the amount reaffirmed as of the date
this disclosure statement is given to the debtor: __________%. If different
simple interest rates apply to different balances included in the amount
reaffirmed,
Form 240A - Reaffirmation Agreement (Cont.)
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the amount of each balance and the rate applicable to it are:
$ _________@ _________%;
$_________ @ _________%;
$_________ @ _________%.
c. If the underlying debt transaction was disclosed as a variable rate transaction on the
most recent disclosure given under the Truth in Lending Act:
The interest rate on your loan may be a variable interest rate which changes from
time to time, so that the annual percentage rate disclosed here may be higher or
lower.
d. If the reaffirmed debt is secured by a security interest or lien, which has not been
waived or determined to be void by a final order of the court, the following items or types of
items of the debtor’s goods or property remain subject to such security interest or lien in
connection with the debt or debts being reaffirmed in the reaffirmation agreement described in
Part B.
Item or Type of Item
Original Purchase Price or Original Amount of Loan
There must be a description of collateral here IF
it's a secured loan
Optional---At the election of the creditor, a repayment schedule using one or a combination of
the following may be provided:
Repayment Schedule:
Your first payment in the amount of $___________ is due on _________(date), but the future
payment amount may be different. Consult your reaffirmation agreement or credit agreement, as
applicable.
— Or —
Your payment schedule will be: _________(number) payments in the amount of $___________
each, payable (monthly, annually, weekly, etc.) on the __________ (day) of each ____________
( week, month, etc.), unless altered later by mutual agreement in writing.
— Or —
A reasonably specific description of the debtor’s repayment obligations to the extent known by
the creditor or creditor’s representative.
Form 240A - Reaffirmation Agreement (Cont.)
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2. INSTRUCTIONS AND NOTICE TO DEBTOR
These 7 'bullet
Reaffirming a debt is a serious financial decision. The law requires you to take certain
points' along
steps to make sure the decision is in your best interest. If these steps are not completed, the
with
reaffirmation agreement is not effective, even though you have signed it.
introductory
paragraph
1. Read the disclosures in this Part A carefully. Consider the decision to reaffirm
must be
included
carefully. Then, if you want to reaffirm, sign the reaffirmation agreement in Part B (or you may
use a separate agreement you and your creditor agree on).
2. Complete and sign Part D and be sure you can afford to make the payments you are
agreeing to make and have received a copy of the disclosure statement and a completed and
signed reaffirmation agreement.
3. If you were represented by an attorney during the negotiation of your reaffirmation
agreement, the attorney must have signed the certification in Part C.
4. If you were not represented by an attorney during the negotiation of your reaffirmation
agreement, you must have completed and signed Part E.
5. The original of this disclosure must be filed with the court by you or your creditor. If a
separate reaffirmation agreement (other than the one in Part B) has been signed, it must be
attached.
6. If the creditor is not a Credit Union and you were represented by an attorney during
the negotiation of your reaffirmation agreement, your reaffirmation agreement becomes effective
upon filing with the court unless the reaffirmation is presumed to be an undue hardship as
explained in Part D. If the creditor is a Credit Union and you were represented by an attorney
during the negotiation of your reaffirmation agreement, your reaffirmation agreement becomes
effective upon filing with the court.
7. If you were not represented by an attorney during the negotiation of your reaffirmation
agreement, it will not be effective unless the court approves it. The court will notify you and the
creditor of the hearing on your reaffirmation agreement. You must attend this hearing in
bankruptcy court where the judge will review your reaffirmation agreement. The bankruptcy
court must approve your reaffirmation agreement as consistent with your best interests, except
that no court approval is required if your reaffirmation agreement is for a consumer debt secured
by a mortgage, deed of trust, security deed, or other lien on your real property, like your home.
