Bill Certification And Payoff Request Form (Page 2 of 2) in pdf

Bill Certification And Payoff Request Form Page 2

2009-03A

TO: Philadelphia Department of Revenue, Agency Receivables -- Fax: 215-686-7871

PLEASE NOTE PHONE NO. CHANGE

DATE: _______________

215-686-6648

215-686-2670

Phone:

BILL CERTIFICATION AND PAYOFF REQUEST FORM

From:

Name:

Phone #:

Fax:

Date of Settlement:

Date Needed By:

PLEASE PROVIDE BY RETURN FAX, PAYOFF AMOUNTS & GOOD THROUGH DATES

FOR ANY LIENS LISTED BELOW, AND FOR ALL BILLS IN YOUR SYSTEM FOR:

File #

Address:

BRT#

_______________________________________________________________________________________

(Type known lien # and date or attach a copy of City's “Agency Receivables Inquire Bill” from title search)

Lien # _____________ violation date ____________ PAYOFF $____________ if paid by ____________

Bills __________________________________________________________________________________

______________________________________________________________________________________

IF THERE WERE BILLS & LIENS IN THE CITY'S SYSTEM PLEASE CHECK HERE:

PRIOR LIENS IN THE CITY'S SYSTEM FOR THIS ADDRESS

EXISTED BUT HAVE BEEN PAID IN FULL

IF THERE ARE NO BILLS & NO LIENS IN THE CITY’S SYSTEM PLEASE CHECK

HERE:

NO BILLS & NO LIENS IN THE CITY'S SYSTEM FOR THIS ADDRESS

AS OF ____________________________ (enter today's date)

Form completed by: ____________________________________ Date:_________________

Dept. of Revenue Employee Name:

Mail payment to:

City of Philadelphia

Department of Revenue

MSB-Concourse Level

Agency Receivables

1401 John

Kennedy Boulevard

Philadelphia PA 19102-1697

Attn: Mrs. Jones

Bill Certification And Payoff Request Form Page 2