Looking for a Small Estate Affidavit? Download it for free!

New York State Comptroller’s Office – Office of Unclaimed Funds

Table of Heirs

Page 2

Date: _____________

Reference Number: ______________

Name

Address

Alive

Death

(Y or N)

Date

IV. Parents of

the Deceased

1. _____________________________| _____________________________________________| ________| ________________

2. _____________________________| _____________________________________________| ________| ________________

Name

Address

S.S.N#

Alive

Death

Spouse

(Y or N)

Date

Name

V. ALL

Brothers

1. _____________________|_________________________ |_________________| ________|_________| ______________________

and

Sisters of

the

2. _____________________|_________________________ |_________________| ________|_________| ______________________

Deceased

3. _____________________|_________________________ |_________________| ________|_________| ______________________

4. _____________________|_________________________ |_________________| ________|_________| ______________________

Name

Address

S.S.N#

Alive

Death

Parent(s)

(Y or N)

Date

Name

VI. ONLY

Children

1. _____________________|_________________________ |_________________| ________|_________| ______________________

of the

Deceased

Brothers

2. _____________________|_________________________ |_________________| ________|_________| ______________________

and

Sisters

3. _____________________|_________________________ |_________________| ________|_________| ______________________

4. _____________________|_________________________ |_________________| ________|_________| ______________________

This table was completed by ___________________________, who is related to the decedent as a __________________________,

and who resides at ________________________________________in the county of __________________________________ and

State of ________________________, and, who being duly sworn, declares under penalty of perjury that the above information is true

and correct to the best of her/his knowledge.

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

or 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.