Requests may be sent to State Home Mortgage via email, as long as the form is completely filled out. Application, Repayment Procedure and Forms.This form is furnished to give you a statement of actual settlement costs. Licensed primary care clinicians can receive loan repayment assistance through the NHSC Loan Repayment Program. Providers must be in an eligible discipline. An IOU (I Owe You) is a legal document that sets out the details of a loan made between two people, a borrower, and a lender. How to fill out the Payoff Request Letter Templates? This form is a statement of final loan terms and closing costs. Compare this document with your Loan Estimate. 1833 Park Avenue SE P.O. Box 2708.