Notice

TO: Name of Mortgage Lender (Mortgagee)

RE: Mortgage dated Date of Mortgage in respect of the property described as Brief
Description of Property (ie. 123 Whiteacre Road, Anyplace, Anywhere)

You are hereby notified that the undersigned will be paying off the above mentioned mortgage on
Date of Payoff of Mortgage.

Please provide us with a Payoff Statement as of that date, including a per diem amount in case the
payoff date is extended.

Dated:

Name of Mortgage Borrower

(Mortgagor)