Rev. 06/22/10
160 East 300 South, PO Box 146711, Salt Lake City, UT 84114-6711
Telephone (801) 530-6747 • Facsimile (801) 526-4387 • Internet: www.realestate.utah.gov
State of Utah
Department of Commerce
Division of Real Estate
NOTICE OF BANKRUPTCY FORM
Please complete, sign, and submit this form by fax, mail, or in person to the Utah Division of Real Estate within ten (10) business
days of the filing of a personal bankruptcy, bankruptcy of a business that transacts the business of residential mortgage loans, a
brokerage bankruptcy, an appraisal business bankruptcy, or the bankruptcy of a business that transacts appraisal management services.
See Utah Code Ann. Sections 61-2-7.2, 61-2b-20(4)(b), 61-2c-205(4)(b), and 61-2e-204(3)(b).
The filing of a bankruptcy notification is required of our licensees and is used in reviewing license status. A filing of bankruptcy is
not an automatic cause for a change in status of a licensee, but is used with other information to determine the fitness for licensure,
therefore, it is important that all factors surrounding the filing be adequately disclosed.
This form has been prepared to aid you in providing the required information and can be used as a guide.
I. YOUR INFORMATION
_______________________________________________________________________________________________________
Your Full Legal Name Home Phone Work Phone Cell Phone
____________________________________________________
Email Address (Required)
____________________________________________________________________________________________________________
Mailing Address City State Zip
II. LICENSES YOU HOLD
( ) Appraisal/License #____________ ( ) Mortgage/License #____________ ( ) Real Estate/License # ____________
( ) NMLS Unique ID# ____________
III. BANKRUPTCY TYPE
_________________________________________________________________________________________________________
Bankruptcy Case Number: _______________ Filing Date: __________________ Judge: ______________________
_________________________________________________________________________________________________________
Name of Bankruptcy Court Address City State Zip
Name of Bankruptcy Attorney: _______________________________ Phone Number of Attorney: ________________________
Briefly describe the nature of the bankruptcy and extenuating circumstances: (If you wish to provide additional information, you may
attach it to this form)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
If there are related bankruptcies, provide description below:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Submit the Notice of Discharge of Bankruptcy to Division of Real Estate, P O Box 146711, Salt Lake City, UT 84114-6711, fax
number: 801-526-4387.
Signature ___________________________________________________ Date ______________________________
