Free Reaffirmation Agreement Cover Sheet - Hawaii

Debtor: Joint Debtor:


Case No.: Chapter 7

REAFFIRMATION AGREEMENT COVER SHEET
[Use this form to provide the statement of total income and expenses required by Fed. R. Bankr. P. 4008(b) (12/1/2008).]

This form must be completed in its entirety and filed, with the reaffirmation agreement attached, within the time set under Rule 4008. It may be filed by any party to the reaffirmation agreement. 1. Creditor's Name: 2. Amount of the debt subject to this $ _______________ on the date of bankruptcy reaffirmation agreement: $ _______________ to be paid under reaffirmation agreement _____% prior to bankruptcy 3. Annual percentage rate of interest: _____% under reaffirmation agreement ( _____ Fixed Rate _____ Adjustable Rate)

4. Repayment terms (if fixed rate): $_______________ per month for __________ months 5. Collateral, if any, securing the debt: Current market value: $ ____________________ Description:

Does the creditor assert that the debt is nondischargeable? _____ Yes _____ No 6. (If yes, attach a declaration setting forth the nature of the debt and basis for the contention that the debt is nondischargeable.) Debtor's Income and Expenses Debtor's Schedule I & J Entries as Stated on Reaffirmation Agreement Total monthly income from Monthly income from all 7A. $ ___________ 7B. $ ___________ Schedule I, line 16 sources after payroll deductions Total monthly expenses from 8A. $ ___________ 8B. Monthly expenses $ ___________ Schedule J, line 18 Total monthly payments on Total monthly payments on 9A. reaffirmed debts not listed on $ ___________ 9B. reaffirmed debts not included in $ ___________ Schedule J monthly expenses Net monthly income (Subtract sum of lines 8B and 9B from line 10B. $ ___________ 7B. If total is less than zero, put the number in brackets.)

hib_400827 12/08 [ECF: Bankruptcy ... Miscellaneous ... Reaffirmation Agreement]

11. Explain with specificity any difference between the income amounts (7A and 7B): 12. Explain with specificity any difference between the expense amounts (8A and 8B): If line 11 or 12 is completed, the undersigned debtor, and joint debtor if applicable, certifies that any explanation contained on those lines is true and correct. /s/____________________________________ /s/____________________________________ Signature of Debtor Signature of Joint Debtor (if applicable, and (only required If Line 11 or 12 is completed) only required if line 11 or 12 is completed) Other Information Check this box if the total on line 10B is less than zero. If that number is less than zero, a presumption of undue hardship arises (unless the creditor is a credit union) and you must explain with specificity the sources of funds available to the Debtor to make the monthly payments on the reaffirmed debt: Was debtor represented by counsel during the course of negotiating this reaffirmation agreement? _____ Yes _____ No If debtor was represented by counsel during the course of negotiating this reaffirmation agreement, has counsel executed a certification (affidavit or declaration) in support of the reaffirmation agreement? _____ Yes _____ No FILER'S CERTIFICATION I hereby certify that the attached agreement is a true and correct copy of the reaffirmation agreement between the parties identified on this Reaffirmation Agreement Cover Sheet. /s/_____________________________ ____________________________________________ Signature Print/Type Name and Signer's Relation to Case

hib_400827 12/08 [ECF: Bankruptcy ... Miscellaneous ... Reaffirmation Agreement]