Payoff Request Form. First name, Last name, Account Number (optional), Phone, Street address, Apartment, suite, etc.You may withdraw a portion of your Contract Value free of any applicable surrender charge and Market Value Adjustment each Contract Year. A. Account Information. Step 1: "Accept" your loan award. (b) The Inventory of Assets form shall be filed with the court within nine months of the date letters issued to the fiduciary or as the court otherwise directs. Dear APPLICANT: Effective today we have withdrawn your application for assistance.