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Small Estates Affidavit Form (S.c.p.a. Section 1310), Table Of Heirs - New York State Comptroller Page 5

Table of Heirs

PAGE -3-

DECEASED ___________________________________________

DATE OF DEATH________________________

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 my

knowledge.

_______________________________________

Sworn to before me this _________ day

Signature

of __________________, 20 _______,

_______________________________________

_______________________________

Social Security / Taxpayer Identification Number*

Signature / Seal - Notary Public

*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.

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 5