Payoff Request Form. First name, Last name, Account Number (optional), Phone, Street address, Apartment, suite, etc.A. Account Information. Use this form to authorize the company to start paying benefits included in a Guaranteed Lifetime Withdrawal Rider and submit it to the Nassau Service Center. Please fill out the form below or see additional contact information below this form. Taxpayers may also be eligible to make a hardship withdrawal. Each plan or IRA has specific rules and guidance for their participants to follow. In the Student Center, scroll down to the Finances area. A. Account Information. This is an example of a payoff letter used in a syndicated loan transaction.