Letter of Debt Re-Affirmation

Letter of Debt Re-Affirmation : Please fill out the following form. Please print your completed form if you would like to have a copy for your records.

FOR GOOD AND VALUABLE CONSIDERATION RECEIVED, the undersignedhereby acknowledges and re-affirms to (name of Creditor) and its successors and assigns, a certain prior debt discharged, released, extinguished or cancelled pursuant to (Applicable statue or code) and that the undersigned shall be and agrees to remain bound on said debt in the amount of $ ______ only and for no greater sum, and to the same extent as if said debt to the amount stated were not discharged in the first instance.

It is further agreed that the above stated re-affirmed debt shall be paid in the following manner :

Terms of payment

In addition, if said debt was discharged pursuant to any provision of the United States Bankruptcy Code, the Undersigned shall diligently make application (before the United StatesBankruptcy Court) for said approval.

This agreement shall be binding upon the parties, their successors, assigns and personal representatives.

Signed this day of (date with year) :

In the presence of :

Witness :

Debtor :

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