Lender Name:

Loan Account:

Phone Number:

Area Code


Phone Number

Is This Loan A:

First MortgageSecond MortgageThird MortgageEquity Line

Borrower Name:

Last Name

First Name

Last 4 Digits of SSN#:

Property Address:

Street Address

Street Address Line 2



Postal/Zip Code


Settlement Agent: Thomas & Brown, LLC

The undersigned hereby authorize the above-referenced Lender to release to Thomas & Brown, LLC and any of its employees and agents acting on its behalf any and all payoff information associated with the loan account referenced above. Please furnish any and all pertinent information to Thomas & Brown, LLC as they may require.

If this account allows for advances of a credit line, the undersigned request and authorize Lender to block this account against all future draws. If Lender makes additional advances, they will not be secured by the above-referenced Property. Upon issuance of a payoff statement and receipt of payment based upon that statement, Lender will be obligated to release the Security Instrument securing the line of credit.

A photocopy of this Authorization bearing the signature of the undersigned may be deemed the equivalent of the original.