Small Estates Affidavit Form (S.c.p.a. Section 1310), Table Of Heirs - New York State Comptroller Page 3
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4THOMAS P. DiNAPOLI
110 STATE STREET
STATE COMPTROLLER
ALBANY, NEW YORK, 12236
STATE OF NEW YORK
OFFICE OF THE STATE COMPTROLLER
OFFICE OF UNCLAIMED FUNDS
Table of Heirs
Date: _____________
Reference Number: ______________
Deceased: _______________________________________________
Date of Death: __________________
If no spouse or blood relatives ever existed in a category, write “none”. If more space is needed in a particular category,
please attach a separate sheet. Any category missing detail may result in delayed processing.
Name
Address
Alive
Death
(Y or N)
Date
I. Spouse of
the Deceased
1. _____________________________| _____________________________________________| ________| ________________
2. _____________________________| _____________________________________________| ________| ________________
Name
Address
S.S.N#
Alive
Death
Spouse
(Y or N)
Date
Name
II. ALL
Children
1. _____________________|_________________________ |_________________| ________|_________| ______________________
of the
Deceased
2. _____________________|_________________________ |_________________| ________|_________| ______________________
3. _____________________|_________________________ |_________________| ________|_________| ______________________
4. _____________________|_________________________ |_________________| ________|_________| ______________________
Name
Address
S.S.N#
Alive
Death
Parent(s)
(Y or N)
Date
Name
III. ONLY
Children
1. _____________________|_________________________ |_________________| ________|_________| ______________________
of the
Deceased
Children
2. _____________________|_________________________ |_________________| ________|_________| ______________________
(Grandchil
dren of
the
3. _____________________|_________________________ |_________________| ________|_________| ______________________
Deceased)
4. _____________________|_________________________ |_________________| ________|_________| ______________________
(Please complete Section IV, V and VI, only if the deceased had no children on Page 2)
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