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2. 
4. Please prepare a payoff quote according to the following information. I understand that this request must be accompanied by written authorization from the borrower, and that the request and borrower authorization must be complete and accurate in order for me to receive a payoff statement.
6. Request Date*
   Request Date
8. Reason for Request (Please Check One)*

   1. Sale of Property

   1. Refinance – Lender’s Name
10. Please provide payoff figures good through*
12. Upload Mortgage/Note for which the payoff is requested*
16. Please Complete Requestor's Information
18. Requestor's Name*
20. Law Firm/Settlement Agent*
22. Email Address*
24. Phone Number*
28. Please Complete Borrower's Information
30. Borrower Name*
32. Co-Borrower*
34. Property Address*
36. Phone Number*
40. Borrower Authorization
42. I*
44. Certify that I am the person named above and I am the homeowner of the property address listed below.
46. Address*
48. City*
49. State*
50. Zip Code*
52. I hereby authorize the above requestor to obtain payoff information on my loan.
54. I authorize The City of North Miami to release said information to the requestor listed above. This authorization will remain in effect for 30 days. I understand that I may revoke this authorization at any time before the payoff information is disclosed, in writing, by mail or e-mail. I further agree to release The City of North Miami from any liability for providing this information.
56. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
58. Electronic Signature*
59. Date*
    Date
Leave This Blank:


61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit

* indicates a required field