Fillable Printable Estate Tax Domicile Affidavit - New York
Fillable Printable Estate Tax Domicile Affidavit - New York
Estate Tax Domicile Affidavit - New York
Complete Form ET-141 if it is claimed that the decedent was not domiciled in New York State at the time of death.
The duciary (executor or administrator), the surviving spouse, or a member of the decedent’s immediate family who can provide
all the information requested below should complete this afdavit.
Answer all questions completely. Submit this form with Form ET-30; ET-85; ET-90 for dates of death before February 1, 2000; ET-130;
ET-133; or ET-706 for dates of death on or after February 1, 2000; as applicable.
Decedent’s last name First Middle initial Social security number
Address of decedent at time of death
(number and street) Date of death
City, village or post ofce County State ZIP code Country of residence
Age of death Date of birth Place of birth
1 If born outside the United States, was the decedent a naturalized citizen of the United States?
If Yes, enter (below) the name and address of the court where the decedent was naturalized. Yes No
Name and address of court where naturalized
2 Did decedent ever live in New York State?
Yes
No
If Yes, list periods.
3 Did decedent ever own, individually or jointly, any
interest in real estate located in New York State? Yes No
If Yes, list addresses and periods below (submit additional sheets if necessary).
Periods of time - from/to Addresses of property
4 Did decedent lease a safe deposit box located in New York State at the time of death? Yes No
If Yes, complete box below. Also, if Yes, has it been inventoried? Yes No
If Yes, submit a copy of inventory.
Name and address of bank where box is located
5
Provide the following information regarding the residences of the decedent during the last ve years preceding death (submit additional sheets if necessary).
New York State Department of Taxation and Finance
New York State Estate Tax Domicile Afdavit
For estates of decedents dying after May 25, 1990
ET-141
(1/15)
Period of time
from - to
Address
Residence
owned - rented
other - explain
Period of time
from - to
Address
Residence
owned - rented
other - explain
6 For the ve years prior to death, list (1) the Internal Revenue Service Centers and (2) the states or other municipalities where the
decedent led income tax returns
(if no income tax returns were led, enter none).
Year Internal Revenue Service Center State, county, or municipality
Privacy notication
New York State Law requires all government agencies that maintain a system of records to provide notication of the legal authority for any
request, the principal purpose(s) for which the information is to be collected, and where it will be maintained. To view this information, visit our
Web site, or, if you do not have Internet access, call and request Publication 54, Privacy Notication. See Need help? for the Web address
and telephone number.
7 List the states where the decedent was registered to vote during the last ve years preceding death (list latest year rst).
Years
State
From To
Date of Death
If decedent did not vote in those ve years, when did he or she last vote? Where?
8 List employment or business activities (if any) engaged in by the decedent during the ve years preceding the date of death.
In New York State
Outside New York State
Period of time
from - to
Nature of employment or business activities
Period of time
from - to
Nature of employment or business activities
Applicant’s last name First name Middle initial Relationship to decedent
Address (number and street) Connection with estate
City, village, or post ofce State ZIP code Country of residence
The undersigned states that this afdavit is made to induce the Commissioner of the Department of Taxation and Finance of the State of New York to determine
domicile, and that the answers herein contained to the foregoing questions are each and every one of them true in every particular.
Signature of Notary Public, Commissioner of Deeds or Authorized New York State
Signature of applicant Department of Taxation and Finance employee (no seal required)
Sworn before me this day of 20
Signature
9 Was decedent a party to any legal proceedings in New York State during the last ve years? Yes No
If Yes, list courts, dates,
and types of action.
11 Did decedent execute any trust indentures, deeds, mortgages, or any other documents
describing his or her residence during the last ve years preceding death?
Yes
No
If Yes, submit a copy.
12 Was the decedent a member of any church, club, or organization? Yes No
If Yes, give name, address, and other details.
(Submit additional sheets if necessary.)
10 Did decedent have a license to operate a business, profession, motor vehicle, airplane, or boat?
Yes
No
If Yes, list below.
License number Type of license Date of issuance Name and location of issuing ofce
13 What other information do you wish to submit in support of the contention that the decedent was not domiciled in New York State at the
time of death?
(Submit additional sheets if necessary.)
ET-141 (1/15) (back)
