By including a per diem amount in the letter, the parties will not have to execute another payoff letter if the termination date. Payoff Request Form.First name, Last name, Account Number (optional), Phone, Street address, Apartment, suite, etc. Please accept this as my authorization to issue a payoff statement to. Through an effective date of . You need to fill out a form to be considered for "Poor Person Relief. The Participation Application from Seller in which Seller seeks approval to participate in the Low Interest Rate Mortgage Program. (b).