| Payer's/Borrower's Information | Recipient/Lender's Information | ||
|---|---|---|---|
| Name: John Doe | SSN: 123-45-6789 | Name: Home Loan Bank | Federal identification no.: 98-7654321 |
| Address: 123 Elm St, Pleasantville, State, 12345 | Address: 987 Lending St, Capital City, State, 67890 | ||
| 1. Mortgage interest received from payer(s)/borrower(s)* | 2. Outstanding mortgage principal | 3. Mortgage origination date | 4. Refund of overpaid interest |
| $10,500.00 | $200,000.00 | 01/15/2018 | $0.00 |
| Other | |||
| Property Address (if different from payer's/borrower's address): Not Applicable | |||
*Note: This form is for illustrative purposes only and should not be considered a legal or official document.
