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THOMAS P. DiNAPOLI

110 STATE STREET

STATE COMPTROLLER

ALBANY, NEW YORK, 12236

STATE OF NEW YORK

OFFICE OF THE STATE COMPTROLLER

OFFICE OF UNCLAIMED FUNDS

Small Estates Affidavit (S.C.P.A. Section 1310)

Date: ________________

Reference Number: _________________

Estate of _____________________________________________________________________________

No Administrator, Executor or other Fiduciary has qualified or been appointed to handle the decedent's estate. Below, I

have initialed the line next to the appropriate section and I have provided the requested information, when necessary.

_____ Section A - To be completed by Surviving Spouse ONLY

I am the surviving spouse of the decedent and 30 days has not passed since the date of death. To the best of my

knowledge, this payment and all other payments made under Section 1310 of the Surrogates Court Procedure

Act, by all debtors of the decedent known to me after diligent inquiry, do not exceed $30,000.00.

_____ Section B - To be completed by Surviving Spouse, Blood Relative or Creditor

I am the decedent's _______________________________________________ and 30 days have passed since

the date of death. (ONLY a surviving spouse, a child over 18 years of age, mother, father, sister, brother may

claim under this section.) To the best of my knowledge, this payment and all other payments made under Section

1310 of the Surrogate's Court Procedure Act, by all debtors of the decedent known to me after diligent inquiry, do

not exceed $15,000.00.

NOTE: For Section B a Table of Heirs Form must be completed and made part of this affidavit.

OR;

I am a creditor of the decedent or a person who has paid or incurred the decedent's funeral expense, and 30

days have passed since the date of death. The debt was 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 $__________________. 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 $15,000.00. NOTE: A copy of the paid funeral bill must be attached.

I am the surviving spouse, child over 18 years of age, mother, father, sister, brother, niece or nephew of the

decedent and I request that payment be made to:

_____________________________________________________________

who has incurred expenses of the decedent and is entitled to reimbursement.

_______________________________________

Relative's Name (Please Print)

_______________________________________

Relationship to Decedent

______________________________________

Relative's Signature

Please be sure to complete and return both pages of the form.

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