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Fillable Printable Small Estate Affidavit - New York

Fillable Printable Small Estate Affidavit - New York

Small Estate Affidavit - New York

Small Estate Affidavit - New York

THOMAS P. DiNAPOLI
STATE COMPTROLLER
STATE OF NEW YORK
OFFICE OF THE STATE COMPTROLLER
OFFICE OF UNCLAIMED FUNDS
110 STATE STREET
ALBANY, NEW YORK, 12236
Small Estates Affidavit (S.C.P.A. Section 1310)
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 Surrogates 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 or brother 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 or brother 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
**PLEASE BE SURE TO COMPLETE AND RETURN BOTH PAGES OF THIS FORM.
Small Estates Affidavit (S.C.P.A. Section 1310)
REFERENCE NUMBER:
_____ 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.
_______________________________________ _______________________________________
Signature Social Security / Taxpayer Identification Number*
*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.
Sworn to before me this _______________ day
of _________________________, 20 _______,
______________________________________
Signature / Seal - Notary Public
Return this form by mail:
Office of Unclaimed Funds
110 State Street
Albany, NY 12236
Submit online:
https://ouf.osc.state.ny.us/ouf/cs
Contact us: nysouf@osc.state.ny.us or 800-221-9311.
Visit our webpage at http://www.osc.state.ny.us/ouf/index.htm.
We invite you to like us on Facebook at facebook.com/nyscomptroller
and follow us on Twitter at @NYSComptroller
NYS Personal Privacy Protection Law Notification: The NYS Comptroller's Office of Unclaimed Funds (OUF) is requesting you to provide your Taxpayer Identification Number and/or
Date of Birth on this form in order to verify your identity and that you're entitled to claim the funds. OUF is authorized to collect this information under Section 1406 of the NYS
Abandoned Property Law. Disclosing this information is voluntary and we will process your claim without it. However, in certain cases OUF is required to report the transaction to the
Internal Revenue Service and/or other taxing authorities. If your claim is subject to such a requirement, and you don’t provide the requested information at this time, we’ll require that
you provide such information prior to payment. The information provided will be maintained in the Unclaimed Funds Processing System which is under the direction of the Assistant
Director of Services of OUF, 110 State Street, Albany, NY 12236
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