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2. Name*
   Requestor's name
3. Email Address*
5. Company Name
7. Phone Number*
   Please include extensions if applicable
8. Fax Number
10. Disclaimer
    Information submitted on this form will be sent via email. To protect sensitive information, do not submit the following information on this form: Social Security numbers, driver’s license numbers, bank account information, routing numbers, medical information, passport numbers, or passwords.
14. Property Address*

    Payoff Property Address

16. Property City*

    Property City

17. Property Zip Code*

    Property Zip Code

19. Parcel Number
    XX-XX-XX-XXX-XXX (Please make sure that the parcel number contains 12 characters, including all spaces). Parcels in townships start with a LETTER followed by a space, then hyphen.
20. Additional Parcel Number (if needed)
22. Payoff Date*
    Payoff Date
    If you know your closing date, please allow sufficient time from closing for your payment to reach our office. Payments made with insufficient funds will be returned
24. Comments/Special Instructions
26. How would like to receive the payoff information?*
    -- Select One --EmailFaxPhone CallLetter via USPSPick up at WRC Office

    Please select from the drop-down menu
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit Submit and Print

* indicates a required field