Please note, this form is applicable for cases filed before October 17, 2005. Please see the Reaffirmation Agreement  for cases filed on or after October 17, 2005.
A print-friendly version of the Reaffirmation Agreement  is available for downloading.
|Debtor’s Name||Bankruptcy Case No.|
|Creditor’s Name and Address|
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 Clerk of the Bankruptcy Court.
As a result of this agreement, the creditor may be able to take your property 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 bankruptcy 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 made in accordance with Bankruptcy Code § 524 (c)).
You are allowed to pay this debt without signing this agreement. 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 creditor has a lien on the property.
If the creditor has a lien on your personal property, you may have a right to redeem the property and eliminate the lien by making a single payment to the creditor equal to the current value of the property, as agreed by the parties or determined by the court. If you cannot afford to redeem the property with one payment, the reaffirmation agreement allows you to pay for the merchandise in monthly installments as agreed upon by you and the creditor.
This agreement is not valid or binding unless it is filed with the clerk of the bankruptcy court. If you were not represented by an attorney during the negotiation of this reaffirmation agreement, the agreement cannot be enforced by the creditor unless 1) you have attended 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 secured by a mortgage or other lien on your real estate.)
All additional Terms Agreed to by the Parties (if any):
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:
Check Applicable Boxes:
Any lien described herein is valid and perfected.
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 nature of dispute is ____________________________.
I believe this agreement [will][will not] impose an undue hardship on me or my dependents.
I believe this agreement is in my best interest because _________________________________
I [considered][did not consider] redeeming the collateral under section 722 of the Bankruptcy Code (11 U.S.C. § 722). I chose not to redeem because _____________________________________
I [was][was not] represented by an attorney during negotiations on this agreement.
(Signature of Debtor)
(Name of Creditor)
(Signature of Creditor Representative)
|_______________________________________ (Signature of Joint Debtor)||Date__________________|
(Signature of Debtor’s Attorney, if any)
(Not required if page 4 contains signed Certification of Debtor’s Attorney, or if the debt is a consumer debt secured by real property.)
United States Bankruptcy Judge