Bankruptcy
DUMBRIGUE LAW FIRM
633 South Fourth Street, 2nd Floor, Suite 9, Las Vegas, Nevada 89101 * (702) 638-0505 Office * (702) 233-0506 Facsimile
OUR BANKRUPTCY FORM
PLEASE FILL OUT OUR BANKRUPTCY INTAKE FORM.  THANK YOU AND SEE YOU SOON!
General Information
Full Name:
 Spouse:
Social Security No.:
 Spouse:
Date of Birth:
 Spouse:
E-Mail Address:
 Spouse:
Street Address:
 Spouse:
Previous Address (if
less than 2 years):
 Spouse:
Home Phone:
 Spouse:
Cell Phone:
 Spouse:
Occupation:
 Spouse:
Employer:
 Spouse:
Employer's Address:
 Spouse:
Work Phone:
 Spouse:
How long at current
job?:
 Spouse:
Previous Employer (if
less than 1 year):
 Spouse:
Why are you considering bankruptcy?:
How many are in your
household?
List all dependants (Name/Age/State whether they live
with you):
Income
Do you pay child
support? How much?
Spouse:
Do you receive child
support?  How much?
 Spouse:
Do you pay alimony?
How much?
 Spouse:
Do you receive
alimony? How much?
 Spouse:
Spouse:
Gross Monthly Income
(Before Taxes):
Income from Real
Estate:
 Spouse:
Spouse:
Interest/Dividends:
Retirement:
 Spouse:
Social Security:
 Spouse:
Workman's Comp:
 Spouse:
Mortgage Loan
Do you rent or own
your home?
Address of Property:
Date Purchased:
Lender's Name:
First Mortgage Monthly
Payment:
Second Mortgage
Monthly Payment:
First Mortgage
Balance Due:
Second Mortgage
Balance Due:
Original Purchase
Price:
Current Value of
Property:
Are you current on
your payments?
 If you are behind, then
by how much?
Co-Signer/
Co-Debtor? Who?
Do you want to keep
your home?
Car Loan
Lender's Name:
 Year/Make/Model:
Date Purchased:
 Balance Due:
Current Value:
 Monthly Payment:
Are you current on
your payments?
 Do you want to keep
your car?
Assets
Cash on hand:
 Bank Accounts (where
located & how much):
Kitchenware
End table
Dresser
Appliances
Chairs
Wall Units
Decorations on walls
Sofa
Linens
Lamps
Love seat
Vacuum
Clocks
Stereo/CD/Radios
Yard Furniture
TV/VCR
Carpets
 Lawn/Pool Equipment
Dining room set
Beds
BBQ
List books, pictures,
art, collectibles:
 Clothing (Value):
Jewelry:
 Sports equipment,
tools, toys, computers:
Interest in Insurance
polices:
 Retirement or
Annuities Monies:
Stocks, bonds, or
interest in Corporation
 Government or
corporate bonds:
Did you received a tax
refund? How much?
 Future interests or life
estates for your benefit:
Auto, trucks, trailers,
other vehicles:
 Boats & accessories:
Do you own property
out of state?
Livestock, pets:
Did you transfer
property w/in 1 year?
 Property of any kind
not listed above?
Monthly Expenses
Second Mortgage:
Rent:
 First Mortgage:
Security Deposit:
 Maintenance Fees:
 Real estate taxes:
Gas (Utility bill):
Electricity:
 Water:
Cable TV:
Home telephone:
 Cell phone:
Food:
Internet:
 Home Maintenance
(repairs, yard):
Medical/Dental:
Clothing:
 Laundry:
Charitable
Contributions:
Transportation (gas,
bus pass):
 Recreation:
Child Care:
Auto payments:
 Auto maintenance:
Education (tuition,
books, trips):
Cigarettes:
 Parking Fees:
Travel costs:
 Newspapers,
magazines, books:
 Attorney's fee:
Auto Insurance:
 Life insurance:
Insurance:
Medical/Dental
Insurance:
Health Insurance:
 Funeral Insurance:
Other Expenses:
Homeowner's/Renter's
Insurance
DISCLAIMER:  No interaction, visit, or e-mail communication with this website constitutes an attorney-client relationship, unless there is a
signed, mutual written agreement with Dumbrigue Law Firm, Ltd.  This website is informational only and you should not rely on any
information contained in these pages without first consulting with a licensed attorney because every case has its own laws, deadlines,
and implications that must also be considered.  

Furthermore, neither the State Bar of Nevada nor any agency of the State Bar of Nevada has certified any lawyer identified here as a
specialist or as an expert.  Anyone considering a lawyer should independently investigate the lawyer's credentials and ability.

Dumbrigue Law Firm, Ltd. is a Debt Relief Agency.  We help people file for bankruptcy relief under the Bankruptcy Code.