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AC 934-P (Rev. 6/09)

STATE OF NEW YORK

OFFICE OF THE STATE COMPTROLLER

BUREAU OF STATE PAYROLL SERVICES

NEXT OF KIN AFFIDAVIT

State of New York

City of

______________________________________

Office of the State Comptroller

County of ______________________________________

Employee’s Name _________________________________

Last 4 Digits of Employee’s SSN ________________________

________________________________________________________________________, being duly sworn, deposes and says:

Town of

1. That she/he resides at __________________________________________,

Village of ________________________________________,

City of

In the county of ______________________________________________________ and State of ________________________________________;

2. That no Executor, Administrator or fiduciary of the estate of said decedent has qualified or been appointed.

3. That she/he is the  surviving spouse.

That the affiant herein is informed and believes that the sum of $______________________________ was due and owing the decedent from the

State of New York at the time of the decedent’s death for ___________________________________________________________________ and

that this payment and all other payments made pursuant to Section 1310 of the Surrogate’s Court Procedure Act by all debtors, known to the affiant

after diligent inquiry, do not in the aggregate exceed thirty thousand dollars ($30,000). This section applies only within thirty (30) days of the death of

the decedent.

4. That she/he is  the surviving spouse

 one or more of the children of the decedent, eighteen years of age or older

 the father or mother

 a brother or sister

 a niece or nephew

Preference being given in the order named if request for payment shall have been made by more than one such person of the decedent

______________________________________________ who died on the ______ day of _______________________, 20____.

That the following are the names and addresses of the persons entitled to and who will receive the money paid:

______________________________________________________________________________________________________________________

Name

Address

Relationship

Social Security Number

______________________________________________________________________________________________________________________

Name

Address

Relationship

Social Security Number

______________________________________________________________________________________________________________________

Name

Address

Relationship

Social Security Number

______________________________________________________________________________________________________________________

Name

Address

Relationship

Social Security Number

That the affiant herein is informed and believes that the sum of $______________________________ was due and owing the decedent from the

State of New York at the time of the decedent’s death for _____________________________________________________________________ and

that this payment and all other payments made pursuant to Section 1310 of the Surrogate’s Court Procedure Act by all debtors, known to the affiant

after diligent inquiry, do not in the aggregate exceed fifteen thousand dollars ($15,000).

5. That the decedent had not, to affiant’s knowledge, designated in writing a person to whom such debt shall be paid upon the decedent’s death.

6. That this affidavit is made for the purpose of directing payment of the said debt to:

 the affiant, or

 ______________________, pursuant to SCPA Section 1310(3) (f), a creditor of the decedent or person who has paid or

incurred the funeral expense of the decedent, not to exceed $5,000 (SCPA §1310(4)), upon the request of the surviving

spouse or of one of the above-named relatives and $ ___________________ remains to be reimbursed to such person.

7. Any person 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.

Subscribed and sworn to before me on

_______________________________________________________________

Signature of Affiant

Social Security Number

this_____day of ___________, 20____.

________________________________

Notary Public

Commissioner of Deeds