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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 Form (S.c.p.a. Section 1310), Table Of Heirs - New York State Comptroller

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