Cash Bail - Surety Survivor'S Affidavit Form - 2015 printable pdf download

NYC DEPARTMENT OF FINANCE

TREASURY DIVISION

C A S H

SURETY SURVIVOR’S AFFIDAVIT

B A I L

Department of Finance

Mail to: NYC Department of Finance, Treasury/Court Assets, 66 John Street, 12th Floor, New York, NY 10038

Instructions: Pursuant to the Surrogates Court Procedure Sec 1310 (3): If a surety entitled to a Cash Bail refund is de-

ceased, such refund may be paid to certain designated relatives or the person that paid the funeral expenses. To claim re-

fund, this affidavit should be completed and signed by the designated relative or the person that paid the funeral expenses.

This form must be notarized and submitted with two pieces of identification, a certified copy of the death certificate and a

paid copy of the funeral bill (if applicable). One of the forms of identification should be a birth certificate, marriage certifi-

cate or other documentation that establishes relationship to the deceased. The other ID must be a valid government pic-

ture ID such as a driver’s license, passport, benefit card, social security card, or employment/school ID. For additional

information visit our Cash Bail/Court & Trust Section at

or contact us at 212-908-7619 or visit us at

nyc.gov/contactcashbail.

S E C T I O N I - A P P L I C A N T / S U R V I V O R I N F O R M A T I O N

1. Name of Survivor/Applicant

(Must be 18 years old):___________________________________________

_______________________________________

PRINT LAST NAME OFSURVIVOR

PRINT FIRST NAME OFSURVIVOR

2. Address: ____________________________________________________________________________ Apt. #: ____________

NUMBER AND STREET

Daytime

City:______________________ County: __________ State: _____ Zip Code: ___________ Phone #: __________________

3. I am the deceased surety’s

spouse

registered domestic partner

child

(Check one):

father or mother

sibling

niece/nephew

S E C T I O N I I - S U R E T Y I N F O R M A T I O N

1. Surety Name: ____________________________

____________________________ Date of Death: ___________________

PRINT LAST NAME OF SURETY

PRINT FIRST NAME OF SURETY

AS STATED ON DEATH CERTIFICATE

2. Address of Surety

(The last residence of the deceased): _________________________________________________________________________

NUMBER AND STREET

City: ___________________________________ County: ________________ State: ________ Zip Code: ______________

S E C T I O N I I I - P A Y M E N T / B A I L I N F O R M A T I O N

1. Indicate the docket and/or treasury receipt number:

____________________________________________

___________________________________________

# (

)

DOCKET

INDICTMENT

TREASURY RECEIPT

IF AVAILABLE

2. The sum of $____________________ was paid by, and is still owed to the deceased surety for payment of cash bail, and was on

deposit with the NYC Department of Finance at the time of his/her death.

3. I direct payment of these monies to one or more of the following:

Myself (Survivor/Affiant); and/or

One or more of Surety's Relative(s) (Either spouse, registered domestic partner, parent, child or children (eighteen years of

age or older), sibling or niece/nephew); and/or

A creditor of the deceased surety or a person who has incurred the funeral expenses of the deceased surety pursuant to

Section 1310 (3)(f) of the Surrogate Court Procedure Act (SCPA)

Visit Finance at nyc.gov/finance

SurvAff. 12.11.2015

Cash Bail - Surety Survivor'S Affidavit Form - 2015

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