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Be sure to remove all notices before using this document.

Modify the wording in this notice to suit your particular
situation. Do NOT just use the wording here unless it definitely
applies to you.
Date:___________________
VIA CERTIFIED MAIL, RETURN RECEIPT REQUESTED NUMBER: XXXXXXXXX
YOUR NAME
YOUR STREET ADDRESS
YOUR CITY, STATE AND ZIP CODE
LENDER NAME
LENDER ADDRESS
LENDER CITY, STATE AND ZIP CODE
RE: ACCT # XXXX-XXXX-XXXX-XXXX
REAL PROPERTY LOCATED AT :__________________________________________
To Whom It May Concern:
Pursuant to the provisions of the Truth and Lending Act (“TILA”), 15 U.S.C. Section 1635, I/we
hereby rescind the above-referenced loan, due to violations of TILA, including but not limited to
the unlawful failure to give timely and proper notices required under TILA.
With this letter, I/we hereby exercise my rights under the Federal Truth in Lending Act, 15
U.S.C. § 1635 and Regulation Z, 12 C.F.R. 226.23(b)(5) to rescind the above referenced
mortgage loan. The Truth in Lending disclosure statement was defective for the following
reason:
STATE THE REASON OR REASONS THAT THE DISCLOSURE STATEMENT WAS
DEFECTIVE. USE THE BELOW WORDING AS AN EXAMPLE ONLY
The notice shall identify the transaction or occurrence and clearly and conspicuously disclose the
following:
INSERT HERE THE REASON SUCH AS FAILURE TO DISCLOSE OR UNDERDISCLOSURE OF APR AND FINANCE CHARGES
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Pursuant to 15 U.S.C. § 1635(f), my/our right to rescind this loan extends for three-years as a
result of this defective Truth in Lending disclosure statement. This rescission notice has been
sent to you within that time period.
I/we have arranged for the refinancing of my mortgage loan with LIST NAME OF
MORTGAGE COMPANY and am prepared to tender the reduced payoff amount once the
proper credits have been reflected in my reduced payoff.
Please be advised that your security interest in my/our home is now void per 15 U.S.C. § 1635;
Regulation Z § 226.23 and you have twenty-days to return all of the payments I have made on
this loan and to do your part to terminate the security interest in my home.
Thank you for your prompt attention to this matter. You may contact me at 555-555-5555 should
you require any further information or would like to discuss this matter further.
Sincerely,
__________________
YOUR SIGNATURE
YOUR NAME

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