Payment Payoff Form

PAYMENT PAYOFF FORM

Parties

Recitals

WHEREAS, Creditor Name: holds an unpaid obligation evidenced by Account/Reference No.: with an outstanding balance as of the effective date of: $ .

WHEREAS, Debtor Name: desires to satisfy said obligation in accordance with the terms set forth in this Payment Payoff Form and Creditor agrees to accept payment on the terms below.

Scope of Work

Describe the actions to be taken by the parties in connection with the payoff, including calculation, documentation, and release of encumbrances:

Payment Terms

Agreed Payoff Amount: $   Payoff Date (target):

One-time payment    Installment plan    Wire transfer    Automatic debit (ACH)

First Payment Due:   Number of Installments:   Installment Amount: $

Late Fee (percent per month): %   OR Flat Late Fee: $.   Late fee applies after days past due.

Term and Termination

Effective Date: . This agreement shall terminate on: , unless earlier terminated in accordance with the notice provisions below.

Confidentiality

Each party shall maintain as confidential and shall not disclose to any third party any non-public information received from the other party in connection with the negotiation and performance of this Payment Payoff Form, except as required by law or to enforce rights under this agreement. Confidential information does not include information that is or becomes publicly available through no breach of this agreement, already in the receiving party's possession, or independently developed by the receiving party.

Authorization and Release

Upon receipt of the Agreed Payoff Amount and any accrued, permitted fees, Creditor shall mark the account as satisfied and prepare and provide, within a commercially reasonable time, any releases, reconveyances, satisfactions of lien, or other documents reasonably necessary to evidence the paid status of the obligation and to permit removal of any liens or encumbrances recorded in connection with the obligation. Debtor authorizes Creditor to apply payments as specified in Payment Terms above.

Representations and Warranties

Each party represents and warrants that it has the full power and authority to enter into this Payment Payoff Form and to perform its obligations hereunder and that the individual signing on behalf of a party is duly authorized to bind that party.

Governing Law

This Payment Payoff Form shall be governed by and construed in accordance with the laws of the State of , without regard to its conflict of laws principles.

Entire Agreement

This Payment Payoff Form, including any schedules or written addenda executed by the parties, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous negotiations, understandings, representations, and agreements, whether written or oral.

Notices

All notices required or permitted under this Payment Payoff Form shall be in writing and delivered to the addresses set forth above or to such other address as a party may designate by notice. Notice shall be effective upon personal delivery, three (3) days after deposit in the United States mail with first-class postage prepaid, or one (1) day after delivery to a nationally recognized overnight courier.

Counterparts

This Payment Payoff Form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument. Electronic or faxed signatures shall be binding for all purposes.

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