Edu for a Payoff Request. This form is furnished to give you a statement of actual settlement costs.To get a mortgage payoff statement, you'll need to contact your lender and provide some personal info. A payoff statement should include the name and address of the lender preparing the statement and be addressed to the lender that requested the payoff. 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? Filling out this form is straightforward.