Payoff Request Form. First name, Last name, Account Number (optional), Phone, Street address, Apartment, suite, etc.By including a per diem amount in the letter, the parties will not have to execute another payoff letter if the termination date. 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. " You may also ask the Court to appoint an attorney to represent you. To get a payoff letter, ask your mortgage lender for an official payoff statement and let them know what the projected closing date is. Depending on your lender, you may have to sign in to an online account, call a helpline, or send a formal letter to start the request process. Late charges are assessed after: 15 days from payment due date.