Payoff Request Form

Borrower Payoff Request
Today's Date

MonthDayYear
Desired Payoff Date

MonthDayYear
(date payment will be received by our office)
Customer Name(s)
Company Name, if applicable
Requestor Name, if not being requested by the owner of the property/loan
Company/Position, if applicable
Address of property you'd like to pay off?
Do you need a partial Payoff?
How would you like the receive the payoff statement?
Fax Number
Please enter a valid phone number.
Email
example@example.com
Reason for Payoff request
Should your auto-draft agreement be discontinued?
Reason you are authorized to receive payoff:
(lienholders and other third parties must provide additional documentation)
Instructions for sending payoff funds will be included in payoff statement and may change depending on account circumstances. Lien(s)will not be released until account is paid in full and funds are confirmed.
Should be Empty: