Sample Forms, Policies, and Contracts. Sample Form of Payoff Letter., for the payoff of the above-referenced loan. Include the payment amount. Include the date you plan to make the payment. Create a Loan Payoff Letter online and download it as a PDF or Word document. Customize and print a blank Loan Payoff Letter for free. This form is furnished to give you a statement of actual settlement costs. The party owed should include language that motivates the debtor to make payment. This is an example of a payoff letter used in a syndicated loan transaction.