Settlement Statement Form

A settlement statement form is a statement that is used for settlement of an outstanding amount at a rate lesser than the original borrowed amount. This form acts as evidence that a certain payment has been made and the individual has no outstanding payment. This form is usually used for settling credit card or loan payments.

Sample Settlement Statement Form:

Details of the borrower:

Name: First name __________ Middle name __________ Surname ____________

Address:  Street address: _______________ Name of city: ___________ State: _______

Postal code: _____________

Date of birth: ________________

Home contact number: _________                          Work contact number: _____________

Mobile number: __________________

Settlement Charges:

Original loan amount:                                                   _________________

Discount amount applicable:                                         _________________

Inspection fee:                                                              ________________

Outstanding interest amount from                                     _______________

________ To __________ at an interest rate

of ___________ per annum

Brokerage fee:                                                                  ________________

Document preparation charges                                       _______________

Lawyer’s fees                                                                   ______________

Loan amount already paid                                               _________________

City stamps:                                                                      ______________

State stamps:                                                                  ___________________

Net settlement amount:                                          ____________________

_____________________

Signature of the borrower

Dated: ______________

Category: Statement Forms