Small Estates Affidavit Form - New York

This New York-specific "Small Estates Affidavit Form" is a document released by the Office of the New York State Comptroller.

Download the fillable PDF by clicking the link below and use it according to the applicable legal guidelines.

ADVERTISEMENT
THOMAS P. DINAPOLI
110 STATE STREET
STATE COMPTROLLER
ALBANY, NEW YORK 12236
STATE OF NEW YORK
OFFICE OF THE STATE COMPTROLLER
OFFICE OF UNCLAIMED FUNDS
Small Estates Affidavit (S.C.P.A. Section 1310)
Date: ____________________
Reference Number: ______________________
ESTATE OF ____________________________________________________________
NO Administrator, Executor or other Fiduciary has qualified or been appointed to handle the
decedent’s estate. Below, I have initialed the line next to the appropriate section and I have
provided the requested information, when necessary.
_____ Section A - To be completed by Surviving Spouse ONLY
I am the surviving spouse of the decedent and 30 days has not passed since the date of
death. To the best of my knowledge, this payment and all other payments made under
Section 1310 of the Surrogate’s Court Procedure Act, by all debtors of the decedent known to
me after diligent inquiry, do not exceed $30,000.00.
_____ Section B - To be completed by Surviving Spouse, Blood Relative or Creditor
I am the decedent’s ________________________________________________________
and 30 days have passed since the date of death. (ONLY a surviving spouse, a child over
18 years of age, mother, father, sister, brother, niece or nephew may claim under this
section.) To the best of my knowledge, this payment and all other payments made under
Section 1310 of the Surrogate’s Court Procedure Act, by all debtors of the decedent known to
me after diligent inquiry, do not exceed $15,000.00.
NOTE: For Section B a Table of Heirs Form must be completed and made part of this
affidavit.
OR;
I am a creditor of the decedent or a person who has paid or incurred the decedent’s funeral
expense, and 30 days have passed since the date of death. The debt was incurred at the
request of the surviving spouse or other entitled blood relatives. I paid the funeral expenses
from my own funds and I have not been reimbursed in full. I am seeking reimbursement in the
amount of $________________. To the best of my knowledge, this payment and all other
payments made under Section 1310 of the Surrogate’s Court Procedure Act do not, in the
aggregate, exceed $15,000.00. NOTE: A copy of the paid funeral bill must be attached.
I am the surviving spouse, child over 18 years of age, mother, father, sister, brother, niece
or nephew of the decedent and I request that payment be made to:
_______________________________________________________________________
who has incurred expenses of the decedent and is entitled to reimbursement.
____________________________________
________________________________
Relative’s Name – Please Print
Relationship to Decedent
_____________________________________
Relative’s Signature
THOMAS P. DINAPOLI
110 STATE STREET
STATE COMPTROLLER
ALBANY, NEW YORK 12236
STATE OF NEW YORK
OFFICE OF THE STATE COMPTROLLER
OFFICE OF UNCLAIMED FUNDS
Small Estates Affidavit (S.C.P.A. Section 1310)
Date: ____________________
Reference Number: ______________________
ESTATE OF ____________________________________________________________
NO Administrator, Executor or other Fiduciary has qualified or been appointed to handle the
decedent’s estate. Below, I have initialed the line next to the appropriate section and I have
provided the requested information, when necessary.
_____ Section A - To be completed by Surviving Spouse ONLY
I am the surviving spouse of the decedent and 30 days has not passed since the date of
death. To the best of my knowledge, this payment and all other payments made under
Section 1310 of the Surrogate’s Court Procedure Act, by all debtors of the decedent known to
me after diligent inquiry, do not exceed $30,000.00.
_____ Section B - To be completed by Surviving Spouse, Blood Relative or Creditor
I am the decedent’s ________________________________________________________
and 30 days have passed since the date of death. (ONLY a surviving spouse, a child over
18 years of age, mother, father, sister, brother, niece or nephew may claim under this
section.) To the best of my knowledge, this payment and all other payments made under
Section 1310 of the Surrogate’s Court Procedure Act, by all debtors of the decedent known to
me after diligent inquiry, do not exceed $15,000.00.
NOTE: For Section B a Table of Heirs Form must be completed and made part of this
affidavit.
OR;
I am a creditor of the decedent or a person who has paid or incurred the decedent’s funeral
expense, and 30 days have passed since the date of death. The debt was incurred at the
request of the surviving spouse or other entitled blood relatives. I paid the funeral expenses
from my own funds and I have not been reimbursed in full. I am seeking reimbursement in the
amount of $________________. To the best of my knowledge, this payment and all other
payments made under Section 1310 of the Surrogate’s Court Procedure Act do not, in the
aggregate, exceed $15,000.00. NOTE: A copy of the paid funeral bill must be attached.
I am the surviving spouse, child over 18 years of age, mother, father, sister, brother, niece
or nephew of the decedent and I request that payment be made to:
_______________________________________________________________________
who has incurred expenses of the decedent and is entitled to reimbursement.
____________________________________
________________________________
Relative’s Name – Please Print
Relationship to Decedent
_____________________________________
Relative’s Signature
Small Estates Affidavit (S.C.P.A. Section)
Page 2
Date: ____________________
Reference Number:______________________
ESTATE OF ____________________________________________________________
_____ Section C – To be completed by Creditor ONLY
I am a creditor of the decedent or a person who incurred the decedent’s funeral expense and
six months have passed since the date of death. The debt was not incurred at the request
of the surviving spouse or other entitled blood relatives. I paid the funeral expenses from my
own funds and I have not been reimbursed in full. I am seeking reimbursement in the amount
of $________________. The decedent was not survived by a spouse or minor child. To the
best of my knowledge, this payment and all other payments made under Section 1310 of the
Surrogate’s Court Procedure Act do not, in the aggregate, exceed $5,000.00. NOTE: A copy
of the paid funeral bill must be attached.
NOTE: If you do not meet the specific criteria outlined in Section A, B or C above, you may
wish to consult with your attorney for advice on how to proceed.
To the best of my knowledge, the decedent had not designated in writing, persons to whom
these funds should be paid.
Anyone receiving payment is accountable to the fiduciary of the decedent (including a
Public Administrator) if a fiduciary is later appointed for the decedent’s estate.
In consideration of the payment of this claim, I will reimburse to the Office of the State
Comptroller and the State of New York the amount due to any additional persons who are
entitled to these funds. Under penalty of perjury, I certify that the information on this
affidavit is true and correct and that the number shown on this affidavit is the correct
Taxpayer Identification Number.
_______________________________________
Sworn to before me this _________ day
Signature
_______________________________________
of __________________, 20 _______,
Social Security / Taxpayer Identification Number*
_______________________________
*The Social Security Number / TIN is optional at this point, but including it
Signature / Seal - Notary Public
may facilitate our research and may avoid a future request for the number.
PERSONAL PRIVACY PROTECTION LAW - In accordance with the Personal Privacy Protection Law, you are advised
that the information requested in this correspondence conforms to the provisions of the New York State Abandoned
Property Law. The information is necessary to determine entitlement to certain unclaimed funds held by the New York
State Comptroller. Failure to provide this information may result in denial of the claim. This information will be retained by
the Director of Services, Office of Unclaimed Funds, 110 State Street, Albany, N.Y. Telephone (800) 221- 9311.
THOMAS P. DINAPOLI
110 STATE STREET
STATE COMPTROLLER
ALBANY, NEW YORK 12236
STATE OF NEW YORK
OFFICE OF THE STATE COMPTROLLER
OFFICE OF UNCLAIMED FUNDS
Table of Heirs
DECEASED _____________________________________________
DATE OF DEATH________________________
IF NO SPOUSE OR BLOOD RELATIVES EVER EXISTED IN A CATEGORY, WRITE “NONE”. IF MORE SPACE IS NEEDED IN A PARTICULAR
CATEGORY, PLEASE ATTACH A SEPARATE SHEET. ANY CATEGORY MISSING DETAIL MAY RESULT IN DELAYED PROCESSING.
Living
Date of
Name
Address
Y or N
Death
Spouse(s)
1.
of
I.
Deceased
2.
Living
Date of
Spouse
Name
Address
S.S.N.*
Y or N
Death
Name
1.
ALL
Children
II.
2.
of
Deceased
3.
4.
Living
Date of
Parent
Name
Address
S.S.N.*
Y or N
Death
Name
1.
ONLY
Children
2.
III.
of
Deceased
Children
3.
4.
Table of Heirs
PAGE -2-
DECEASED ___________________________________________
DATE OF DEATH________________________
COMPLETE SECTION IV, V AND VI, ONLY IF THE DECEASED HAD NO CHILDREN
Living
Date of
Name
Address
Y or N
Death
Parents
1.
IV.
of
Deceased
2.
Living
Date of
Spouse
Name
Address
S.S.N.*
Y or N
Death
Name
1.
ALL
Brothers
and
2.
V.
Sisters
of
3.
Deceased
4.
Living
Date of
Parent
Name
Address
S.S.N.*
Y or N
Death
Name
1.
ONLY
2.
Children
of
VI.
3.
Deceased
Brothers
and
4.
Sisters
5.
6.
Table of Heirs
PAGE -3-
DECEASED ___________________________________________
DATE OF DEATH________________________
This table was completed by _______________________________________________________, who is related to the
decedent as a __________________________, and who resides at ________________________________________
in the county of _____________________________ and State of __________________________________, and, who
being duly sworn, declares under penalty of perjury that the above information is true and correct to the best of my
knowledge.
_______________________________________
Sworn to before me this _________ day
Signature
of __________________, 20 _______,
_______________________________________
_______________________________
Social Security / Taxpayer Identification Number*
Signature / Seal - Notary Public
*The Social Security Number / TIN is optional at this point, but including
it may facilitate our research and may avoid a future request for the number.
PERSONAL PRIVACY PROTECTION LAW - In accordance with the Personal Privacy Protection Law, you are advised that the
information requested in this correspondence conforms to the provisions of the New York State Abandoned Property Law. The
information is necessary to determine entitlement to certain unclaimed funds held by the New York State Comptroller. Failure to
provide this information may result in denial of the claim. This information will be retained by the Director of Services, Office of
Unclaimed Funds, 110 State Street, Albany, N.Y. Telephone (800) 221- 9311.

Download Small Estates Affidavit Form - New York

431 times
Rate
4.6(4.6 / 5) 22 votes
ADVERTISEMENT
Page of 5