Edit, sign, and share sample payoff letter for private mortgage online. No need to install software, just go to DocHub, and sign up instantly and for free.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. This form is furnished to give you a statement of actual settlement costs. How to fill out the Mortgage Payoff Statement Request Form? To request a payoff quote, please complete the payoff quote form. Complete the "After Recording" and "Prepared By" statements and fill in the name of the county. 1 You must itemize deductions on Schedule A (Form 1040). The loan must be a secured debt on a qualified home.