Official Form, 427 Cover Sheet for Reaffirmation Agreement

The following cover sheet has to be completed and submitted by any party to a reaffirmation agreement. After the form has been submitted, the completed cover sheet has to be attached to the reaffirmation agreement. You can ask the US Bankruptcy Court for the timeframe allowed for filing the documents in accordance with Bankruptcy Rule 4008. The following form is authorized by the Judicial Conference and has to be used under the Bankruptcy Rule 9009.

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Official Form 427Cover Sheet for Reaffirmation Agreement
page 1Official Form 427 	
Cover Sheet for Rea
ffirmation Agreement	12/15	
Anyone who is a party to a reaffirmation agreement may fill out an d file this form. Fill it out completely, attach it to the reaffirmation agreement, 
and file the documents within the time set under Bankruptcy Rule 4008.  
Part 1:  Explain the Repayment Terms of the Reaffirmation Agreement 
1.	W

ho is the cred	
itor?	____	

______________________________________________________________________________________________________ 
Name of the creditor 	
 	
2.	Ho	w much is the debt? On the date that the bankruptcy case is filed   $__________________ 
To be paid under the reaffirmation agreement  $__________________ 
$________ per month for ______ months (if fixed interest rate) 
3.	What is 	 the Annu	al	Pe	
rcentage Rate (APR	)	of in	

terest? (See
Bankruptcy Co	
de
§ 524(k	

)(3)(E).) Before the bankruptcy case was filed  __________________%
   
Under the reaffirmation agreement   __________________% 	
	 Fixed rate	
	Adjustable rate	
4.	Does c	ollateral 	secure	t	
he debt	?		No	
	Yes.  Describe the collatera	l.	____	 ____________________________________________________________________  
Current market value   $__________________  	
5.	Does t	he credit	or assert	that the de	
bt 	is	non	

dischargeable?		No	
	Yes.  Attach an explanation of the nature of the debt and  the basis for contending that the debt is nondischargeable.	
6.	Using i	nformation fr	om	Sched	
ule I: Your Income
(Official Form 106I)  an	
d	Sched	

ule J: Yo	
ur	Expense	

s 	
(Official Form	106J) , fill i	

n the amounts.	Income and expenses repor ted on Schedules I and J 	Income and expenses stated on  the reaffirmation agreement 	
6a. Combined monthly income from 
line 12 of Schedule I  $ _____________ 6e. Monthly income from all sources 
after payroll deductions   $ ______________
6b. Monthly expenses from line 22c o	f 
Schedule J –	$ ___________ 6f. Monthl	 y expenses 	–	$ ______________	
6c. Monthly payments on all 
reaffirmed debts not listed on 
Schedule J 	–	$ ___________ 6g. 	 Monthly payments on all 
reaffirmed debts not included in 
monthly expenses 	–	$ ______________	
6d. Scheduled net monthly income
Subtract lines 6b and 6c from 6a. 
If the total is less than 0, put the 
number in brackets.   $ ____________  6h.
 Present net monthly income 
Subtract lines 6f and 6g from 6e. 
If the total is less than 0, put the 
number in brackets.   $ ______________	
Debtor 1  __________________________________________________________________   	First Name 
Middle Name Last Name	 	
Debtor 2  ________________________________________________________________ (Spouse, if filing)	 First Name  Middle Name Last Name	 	
United States Bankruptcy Court for the:	 __________	 District of 	__________ 	
Case number  ___________________________________________  (If known) 
  Fill in this information to identify your case:

Debtor 1  _______________________________________________________ Case number 	(if known )	_____________________________________  	First Name  Middle Name  Last Name	  Official Form 427
Cover Sheet for Reaffirmation Agreement
page 2
7.
Are the income amounts
on lines 6a and 6e
different?	
	No	
	Yes.  Explain why they are different and complete line 10._____________________________________________
______________________________________________________________________________________ 	
8.	A	re the expenseamounts on lines	 6b	and 6	

f different	
?	
	No	
	Yes.  Explain why they are different and complete line 10.______________________________________________
______________________________________________________________________________________ 	
9.	Is 	the net monthlyincome in line 6h	 less	than 0?	
	No	
	Yes.  A presumption of hardship arises (	unless the creditor is a credit union).	
Ex	

plain how the debtor will make monthly payments  on the reaffirmed debt and pay other living expenses. 
Complete line 10. 
______________________________________________________________________________________ 
______________________________________________________________________________________  	
10.	Debt	or’s certification
about lines 7-9	
If any answer on lines 7-9 is 
Yes, the debtor must sign 
here.
I

f all the answers on lines 7-9 
are  No, go to line 11.	
I certif	
 y that each explanation on lines 7-9 is true and correct.	
	________________________________________ 
Signature of Debtor 1	 	
	___________________________	 	
Signature of Debtor 2 (Spouse Only in a Joint Case)  	
11.	Did an 	
attorney represen	t	the d	
ebtor in negotiating
the reaffirmatio	
n	agreeme	

nt?		No	
	Yes. Has the attorney executed a declaration or  an affidavit to support the reaffirmation agreement?	
	No	
	Yes	
Part 2:  Sign Here 
Whoever fills out this form 
must sign here.  I certify that the attached agreement is a true and correct copy of the reaffirmation agreement
 between the 
parties identified on this  Cover Sheet for Reaffirmation Agreement .  	
	_____________________________________________________________ 	Date   _________________ 	Signature   MM  / DD / YYYY	 
 _____________________________________________________________________ 	
Printed Name
Check one: 
	Debtor or Debtor’s Attorney  	
	Creditor or Creditor’s Attorney