Small Estates Affidavit Form (S.c.p.a. Section 1310), Table Of Heirs - New York State Comptroller Page 2

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New York State Comptroller’s Office – Office of Unclaimed Funds
Small Estates Affidavit (S.C.P.A. Section 1310)
Page 2
Date: ________________
Reference Number: _________________
_____ Section C - To be completed by Creditor ONLY
I am a creditor of the decedent or a person who incurred the decedent's funeral expense and six months have passed
since the date of death. The debt was not 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 $________________. The decedent was not survived by a spouse or minor child. 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 $5,000.00. NOTE: A copy of the paid funeral bill must be attached.
NOTE: If you do not meet the specific criteria outlined in Section A, B or C above, you may wish to consult with your
attorney for advice on how to proceed.
____________________________________________________________________
To the best of my knowledge, the decedent had not designated in writing, persons to whom these funds should be paid.
Anyone 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.
In consideration of the payment of this claim, I will reimburse to the Office of the State Comptroller and the State of New
York the amount due to any additional persons who are entitled to these funds. Under penalty of perjury, I certify that the
information on this affidavit is true and correct and that the number shown on this affidavit is the correct Taxpayer
Identification Number.
-
-
CLAIMANT’S SIGNATURE
* CLAIMANT’S TAXPAYER IDENTIFICATION NUMBER(SSN/FEIN)
*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.
Please complete this form and mail it to:
Sworn to me this ____________ day of ___________ 20 _______
Office of Unclaimed Funds
110 State Street
______________________________________________________
Albany, NY 12236
NOTARY SIGNATURE
For assistance contact us by telephone at 800-221-9311 or at We can also be reached by
email at nysouf@osc.state.ny.us.
NYS PERSONAL PRIVACY PROTECTION LAW NOTIFICATION: In accordance with the requirements of the NYS Personal Privacy Protection Law, you are advised that
the personal information requested on this form is being requested by the NYS Comptroller's Office of Unclaimed Funds (OUF). The OUF is authorized to collect this
information under the Comptroller's authority under Section 1406 of the NYS Abandoned Property Law to process claims to abandoned property. Please note that the
disclosure of your Social Security Number and Date of Birth on this form is completely voluntary and your claim will be processed even if your Social Security Number and/or
Date of Birth is not disclosed. However, in certain cases the Comptroller is required to report the transaction, including your Social Security Number, to the Internal Revenue
Service and other taxing authorities. If we determine that your claim is subject to such a requirement, and you do not provide your Social Security Number at this time, we will
require that you provide such information prior to payment. The personal information that is being requested, including your Social Security Number and Date of Birth, will be
used by the OUF to verify your identity and your entitlement to the property being claimed. Your failure to provide this personal information may result in further processing
time for your claim, and could, in some circumstances, result in denial of the claim where you are not otherwise able to document your identity or entitlement to the property
held by the OUF. The personal information being provided will be maintained in the Unclaimed Funds Processing System which is under the direction of the Director of
Services of the OUF, 110 State Street, Albany, NY 12236.

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