This form contains 36 fields organized into 12 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Borrower Name and SSN
Borrower's Name Text
Enter the borrower's full legal name exactly as it appears on official documents (first, middle initial if any, and last name).
Borrower's SSN Text
Enter the borrower's nine-digit Social Security Number (include dashes or spaces as normally written, e.g., 123-45-6789).
Borrower Name Parts (Middle Name, Last Name, Name Suffix)
Middle Name Text
Enter your middle name (if you have no middle name, type N/A).
Last Name Text
Enter your last name / family surname as it appears on official documents.
Name Suffix Text
Enter any name suffix (for example Jr., Sr., III); if you do not have a suffix, type N/A.
Fifth Loan Row
Fifth Loan Code Text
Enter the loan code letter or number that identifies the type of this loan as shown on the form.
Fifth Loan Holder/Servicer Name, Address and Phone Text
Enter the full name and mailing address of the loan holder or servicer for this loan, including city, state and area code/phone number.
Fifth Loan Account Number Text
Enter the account number for this loan exactly as it appears on your statement or payment book; leave blank if you cannot find it.
Fifth Estimated Payoff Amount Number
Enter the estimated amount needed to pay off this loan, including any unpaid interest, late fees, and collection costs.
First Loan Row
First Loan - Loan Code Text
Enter the loan code from the table above that identifies the type of loan (for example a letter or digit shown in the Loan Code column).
First Loan - Loan Holder/Servicer Name, Address, and Phone Text
Enter the full name and mailing address of the loan holder or servicer (at minimum provide the name, city, and state) and include the area code/phone number.
First Loan - Loan Account Number Text
Enter the account number for this loan exactly as shown on your statement or payment book; leave blank if you cannot find it.
First Loan - Estimated Payoff Amount Number
Enter the estimated amount needed to pay off the loan, including any unpaid interest, late fees, and collection costs.
Fourth Loan Row
Fourth Loan Code Text
Enter the loan code (single letter or digit) that identifies the loan type, matching one of the codes in the loan code table above.
Fourth Loan Holder/Servicer Name, Address, and Phone Text
Enter the full name and mailing address of the loan holder or servicer and include the city, state, and area code/phone number for where payments should be sent.
Fourth Loan Account Number Text
Enter the account number for this loan as shown on your statement or payment book; if you cannot find the account number, leave this field blank.
Fourth Estimated Payoff Amount Number
Enter the estimated total amount needed to pay off this loan, including any unpaid interest, late fees, and collection costs.
Page 5
Today's Date Date
Provide today's date.
Second Loan Row
Second Loan - Loan Code Text
Enter the loan code (letter or short code) that identifies the type of the second loan as shown on the form’s loan code list.
Second Loan - Loan Holder/Servicer Name and Address Text
Enter the full name and mailing address of the loan holder or servicer for the second loan, and include the area code/phone number.
Second Loan - Loan Account Number Text
Enter the account number for the second loan as it appears on your statement or payment book, or leave blank if you cannot find it.
Second Loan - Estimated Payoff Amount Number
Enter the estimated amount needed to pay off the second loan, including any unpaid interest, late fees, and collection costs.
Section 2: Where to Send Your Completed Request (Mailing Address)
Section 2 Mailing Address Text
Enter the complete mailing address where you will send the completed form, including recipient or department name, company/servicer, street address (or P.O. Box), city, state, ZIP code, and any attention or unit information.
Section 3: Help with Completing this Form (Contact Info)
Section 3 – Help Contact (phone/address) Text
Enter the telephone number, mailing address, or other contact information to call or contact for help completing this form.
Seventh Loan Row
Seventh Loan Code Text
Enter the loan code (the single-letter or numeric code from the loan code table) that identifies the type of the seventh loan.
Seventh Loan Holder/Servicer Name, Address and Phone Text
Enter the full name, mailing address (city and state at minimum), and area code/phone number of the loan holder or loan servicer for the seventh loan.
Seventh Loan Account Number Text
Enter the account number for the seventh loan as shown on your loan statement or payment book.
Seventh Estimated Payoff Amount Number
Enter the estimated amount needed to pay off the seventh loan, including any unpaid interest, late fees, and collection costs.
Sixth Loan Row
Sixth Loan - Loan Code Text
Enter the loan code (letter or number) that identifies the type of this loan using the code list on the form.
Sixth Loan - Loan Holder/Servicer Name and Address Text
Enter the full name and mailing address of the loan holder or servicer for this loan, including city, state, and area code/phone number.
Sixth Loan - Loan Account Number Text
Enter the account number for this loan as shown on your statement or payment book; leave blank if you cannot find it.
Sixth Loan - Estimated Payoff Amount Number
Enter the estimated amount needed to pay off this loan, including any unpaid interest, late fees, and collection costs.
Third Loan Row
Third Loan - Loan Code Text
Enter the loan code that identifies the loan type (choose the single letter or number code from the loan-code table above).
Third Loan - Loan Holder/Servicer Name, Address, and Area Code/Phone Text
Enter the full name and mailing address of the loan holder or servicer and include an area code and phone number; provide at least the name, city, and state of the loan holder/servicer.
Third Loan - Loan Account Number Text
Enter the account number for this loan exactly as shown on your statement or payment book; if you cannot find it, leave this field blank.
Third Loan - Estimated Payoff Amount Number
Enter the estimated total amount needed to pay off the loan, including any unpaid interest, late fees, and collection costs.