Free Reaffirmation Agreement Coversheet for Debtor(s) With No Attorney (10/1/01) [NOTE: Only for Use w/ PRE 10/17/05 Case] - Oregon

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 BLANKS ON THIS FORM AND ATTACH COPIES OF ALL DOCUMENTS REQUIRED BELOW.

Debtor(s)

IF DOCUMENTS ARE DEFICIENT IN ANY WAY, THEY WILL BE RETURNED AND WILL NOT BE CONSIDERED BY THE COURT!]

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: $______________ "TOTAL MONTHLY INCOME" LISTED ON SCHEDULE I: $______________ "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. Date: __________ Creditor's Signature: __________________________________ Title: __________________________________
718 (10/1/01)