A secured lender shall prepare and deliver a payoff demand statement to the person who has requested it within fourteen days after receipt of the demand. How to fill out the Payoff Request Letter Templates?Do you need a loan payoff request form? This form is furnished to give you a statement of actual settlement costs. A payoff statement or a mortgage payoff letter will typically show the balance you must pay in order to close your loan. Simply fill out the Escrow Account Set Up Request Form. This form is a statement of final loan terms and closing costs.