Small Estates Affidavit (S.C.P.A. Section 1310) ESTATE OF

THOMAS P. DiNAPOLI STATE COMPTROLLER

110 STATE STREET 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)

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)

Page 2.

_____ 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

NYS PERSONAL PRIVACY PROTECTION LAW NOTIFICATION: In accordance with the requirements of the NYS Personal Privacy Protection Law, you are advised that the personal information requested on this form is being requested by the NYS Comptroller's Office of Unclaimed Funds (OUF). The OUF is authorized to collect this information under the Comptroller's authority under Section 1406 of the NYS Abandoned Property Law to process claims to abandoned property. Please note that the disclosure of your Social Security Number and Date of Birth on this form is completely voluntary and your claim will be processed even if your Social Security Number and/or Date of Birth is not disclosed. However, in certain cases the Comptroller is required to report the transaction, including your Social Security Number, to the Internal Revenue Service and other taxing authorities. If we determine that your claim is subject to such a requirement, and you do not provide your Social Security Number at this time, we will require that you provide such information prior to payment. The personal information that is being requested, including your Social Security Number and Date of Birth, will be used by the OUF to verify your identity and your entitlement to the property being claimed. Your failure to provide this personal information may result in further processing time for your claim, and could, in some circumstances, result in denial of the claim where you are not otherwise able to document your identity or entitlement to the property held by the OUF. The personal information being provided will be maintained in the Unclaimed Funds Processing System which is under the direction of the Director of Services of the OUF, 110 State Street, Albany, NY 12236.

FOR ASSISTANCE TELEPHONE - 1-800-221-9311



THOMAS P. DiNAPOLI STATE COMPTROLLER

110 STATE STREET ALBANY, NEW YORK, 12236

STATE OF NEW YORK OFFICE OF THE STATE COMPTROLLER

OFFICE OF UNCLAIMED FUNDS

Table of Heirs

Date:

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.

Name

I. Spouse of the Deceased 1.

Address |

Alive (Y or N)

|

|

Death Date

2.

|

|

|

Name

II. ALL Children 1. of the Deceased

2.

3.

4. Name

III. ONLY

Children 1.

of the

Deceased

Children 2.

(Grandchil

dren of

the

3.

Deceased)

4.

Address

| | | |

Address

| | | |

S.S.N#

Alive Death (Y or N) Date

|

|

|

|

|

|

|

|

|

|

|

|

|

|

|

|

S.S.N#

Alive Death (Y or N) Date

|

|

|

|

|

|

|

|

|

|

|

|

|

|

|

|

Spouse Name

Parent(s) Name

(Please complete Section IV, V and VI, only if the deceased had no children on Page 2)

New York State Comptroller's Office ? Office of Unclaimed Funds Table of Heirs

Page 2

Name

IV. Parents of the Deceased 1.

Address |

Alive (Y or N)

|

|

Death Date

2. Name

V. ALL

Brothers 1.

and

Sisters of

the

2.

Deceased

3.

| Address

| | |

S.S.N#

|

Alive Death (Y or N) Date

|

Spouse Name

|

|

|

|

|

|

|

|

|

|

|

|

4.

Name

VI. ONLY Children 1. of the Deceased Brothers 2. and Sisters

3.

| Address

| | |

|

|

|

|

S.S.N#

Alive Death (Y or N) Date

|

|

|

|

|

|

|

|

|

|

|

|

Parent(s) Name

4.

|

|

|

|

|

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 her/his knowledge.

-

-

CLAIMANT'S SIGNATURE

* CLAIMANT'S TAXPAYER IDENTIFICATION NUMBER(SSN/FEIN)

*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 me this

day of

20

NOTARY SIGNATURE

Please complete this form and mail it to:

Office of Unclaimed Funds 110 State Street

Albany, NY 12236

or assistance contact us by telephone at 800-221-9311 or at osc.state.ny.us. We can also be reached by email at nysouf@osc.state.ny.us.

NYS PERSONAL PRIVACY PROTECTION LAW NOTIFICATION: In accordance with the requirements of the NYS Personal Privacy Protection Law, you are advised that the personal information requested on this form is being requested by the NYS Comptroller's Office of Unclaimed Funds (OUF). The OUF is authorized to collect this information under the Comptroller's authority under Section 1406 of the NYS Abandoned Property Law to process claims to abandoned property. Please note that the disclosure of your Social Security Number and Date of Birth on this form is completely voluntary and your claim will be processed even if your Social Security Number and/or Date of Birth is not disclosed. However, in certain cases the Comptroller is required to report the transaction, including your Social Security Number, to the Internal Revenue Service and other taxing authorities. If we determine that your claim is subject to such a requirement, and you do not provide your Social Security Number at this time, we will require that you provide such information prior to payment. The personal information that is being requested, including your Social Security Number and Date of Birth, will be used by the OUF to verify your identity and your entitlement to the property being claimed. Your failure to provide this personal information may result in further processing time for your claim, and could, in some circumstances, result in denial of the claim where you are not otherwise able to document your identity or entitlement to the property held by the OUF. The personal information being provided will be maintained in the Unclaimed Funds Processing System which is under the direction of the Director of Services of the OUF, 110 State Street, Albany, NY 12236.

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