Payoff Request Form. Please accept this as my authorization to issue a payoff statement to.Through an effective date of . This is a sample Florida mortgage payoff authorization form and should not be used or relied upon for any real estate transaction. Private Loan Payoff Letter Template offers a clear and professional format for requesting an official statement of your loan payoff balance. Include your case number, the date of the payoff and your email address in your request. We will email the payoff statement to you upon receiving your request. Private Loan Payoff Letter Template offers a clear and professional format for requesting an official statement of your loan payoff balance. Miami, Florida 33128. T 786-469-5200; F 305-329-1535. MiamiDade.