Hooker Information and

Mortgage Payoff Request Form

Hooker Address To Be Payoff _________________________________________________________

Name _________________________________ Name ___________________________________

Social Security __________________________ Cell Phone ______________________________

Male Female Male Female

Single Married Divorce Pending Widowed Single Married Divorce Pending Widowed

Email Address _________________________________ Email Address _________________________________

Address if needed ______________________________ Address if needed ______________________________

City ____________ State ____________ Zip_________ City ____________ State ____________ Zip_________

Days start_____________ Days end_______________

Payoff Payment Fee

Payoff Balance Fee _________________________________________________________________

Hospitality Fee ________________________

Shelter Fee ___________________________

Total Fee _____________________________

Manager hereby confirms accuracy of the above information and authorized Diana Smith and its
Hookers to obtain freedom from Diana, judgment, lien and/or municipal utility information relating to
the hooker including but not limited to payoff amount and get her freedom.

_____________________ Date ___________/________________________ Date ______________

Manager Signature Payoff Signature

Note: All payment should be made due to manager instruction