MACGREGOR ABSTRACT CORPORATION



MACGREGOR ABSTRACT CORPORATION

COMBINED FEDERAL ESTATE TAX AND

NEW YORK STATE ESTATE TAX AFFIDAVIT

(Decedent’s Death After 2/1/2000)

Title No. ________________

Premises: _______________

_______________________

STATE OF NEW YORK )

COUNTY OF _____________ ) SS.:

____________________________________, being duly sworn deposes and says:

I reside at _____________________________________________________________.

I am the (Executor-Administrator)* of the Estate of __________________________ who

died a resident of ______________________ County on ____________________, ______.

(* If neither of the above, state relationship to decedent ______________________________)

I am fully familiar with the assets of which the decedent died seized. The value of the decedent’s gross Federal estate, as defined by the Internal Revenue Code, is less than

$ _____________, and therefore the decedent’s estate is not subject to Federal Estate Tax or New York Estate Tax. (Delete reference to New York Estate Tax if amount is greater the exempt amount set forth on the Notes on reverse side.)

I make this statement knowing full well that ___________________Title Insurance Company and its agent MacGregor Abstract Corporation are relying on the truth of the statements herein for the purposes of issuing its policy of title in the captioned matter.

_____________________________

Sworn to before me this ____________

day of _______________, 20____.

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