View a Sample Settlement Statement to learn more about what to expect at settlement and to familiarize yourself with the language and terms of settlement. This form is furnished to give you a statement of actual settlement costs.Payoff requests, including borrower's authorization, should be directed to the servicer of the first mortgage. A lender's payoff statement or letter will show the amount you need to pay to completely close out the loan. Do you need a loan payoff request form? The mortgage payoff statement is a document that provides a comprehensive breakdown of the remaining balance on a mortgage. Settlement Statement. 8. Before you send in a check, contact your lender and get a written payoff statement. That statement will include a per-diem interest. Maryland Mortgage Lender License 19468.