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Form It-59 Draft - Tax Forgiveness For Victims Of The September 11, 2001 Terrorist Attacks Page 3

DRAFT

IT-59 (12/15) Page 3 of 4

Part 3 – Survivor’s affidavit

The State of New York, County of

, being duly sworn, deposes and says that:

(Print name)

(1) (S)he resides at

town

village of

, in the county of

city

and the state of

, with the ZIP code

(2) (S)he is the:

surviving spouse (Complete Sections A and C if you are submitting this affidavit pursuant to SCPA 1310(2). Complete

(A)

Sections B and C if you are submitting this affidavit pursuant to SCPA 1310(3).)

(B)

child; 18 years or older (complete Sections B and C)

(C)

father or mother (complete Sections B and C)

(D)

brother or sister (complete Sections B and C)

(E)

niece or nephew (complete Sections B and C)

)

of the decedent

(decedent’s social security number

(print name of deceased taxpayer)

who died on the

day of

(month)

(year)

Section A

If box (A) is checked and this affidavit is being submitted pursuant to SCPA 1310(2), I attest that:

(1) I am the surviving spouse of the decedent.

(2) Probate of the decedent’s estate has not begun. No fiduciary of said estate has qualified or been appointed.

(3) No designation of a beneficiary is in effect.

(4) At the time of his/her death, there was due and owing to said decedent an amount of tax forgiveness to be determined by the

Department of Taxation and Finance, upon receipt of this form.

(5) I make this affidavit to obtain payment of the sum of tax forgiveness determined to be due by the Department of Taxation and

Finance, in full satisfaction of the aforesaid debt due and owing to the decedent.

(6) The payment requested herein and all payments received by me under the provisions of SCPA 1310(2) do not in the aggregate

exceed thirty thousand ($30,000) dollars.

590003150099

Form It-59 Draft - Tax Forgiveness For Victims Of The September 11, 2001 Terrorist Attacks Page 3

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