Looking for a New York State Legal Forms And Templates? Download it for free!

Small Estates Affidavit (S.C.P.A. Section)

Page 2

Date: ____________________

Reference Number:______________________

ESTATE OF ____________________________________________________________

_____ 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.

_______________________________________

Sworn to before me this _________ day

Signature

_______________________________________

of __________________, 20 _______,

Social Security / Taxpayer Identification Number*

_______________________________

*The Social Security Number / TIN is optional at this point, but including it

Signature / Seal - Notary Public

may facilitate our research and may avoid a future request for the number.

PERSONAL PRIVACY PROTECTION LAW - In accordance with the Personal Privacy Protection Law, you are advised

that the information requested in this correspondence conforms to the provisions of the New York State Abandoned

Property Law. The information is necessary to determine entitlement to certain unclaimed funds held by the New York

State Comptroller. Failure to provide this information may result in denial of the claim. This information will be retained by

the Director of Services, Office of Unclaimed Funds, 110 State Street, Albany, N.Y. Telephone (800) 221- 9311.

Small Estates Affidavit Form (S.c.p.a. Section 1310), Table Of Heirs - New York State Comptroller Page 2