Chirco Title Agency



Payoff Request Authorization Form

To: _________________________________________________

____________________________________________________

Phone#______________________/Fax#___________________

Loan #______________________

Borrower(s) Name(s): ____________________________________________

____________________________________________

Borrower(s) Social Security No. _______________________________

_______________________________

Property Address_____________________________________________________________________

This is to advise that the above subject property is being sold or refinanced. The mortgage you hold will be paid in full. Please provide payoff figures good through_____________________________________.

Please include per diem & property tax information (if applicable).

I/we authorize you to release the information requested above as soon as possible to:

Chirco Title Agency, Inc.

26800 Harper Ave.

St. Clair Shores, MI 48081

586.772.7020 phone

586.772.3534 fax

Thank You,

_______________________ _______________________

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