Form Et-141 - New York State Estate Tax Domicile Affidavit Page 2
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2ET-141 (1/99) (back)
7 List the states where the decedent was registered to vote during the last five years preceding death
(list latest year first).
Years
State
From
To
Date of death
If decedent did not vote in those five years, when did he or she last vote?
Where?
8 List employment or business activities (if any) engaged in by the decedent during the five years preceding the date of death.
In New York State
Outside New York State
Period of time
Period of time
Nature of employment or business activities
Nature of employment or business activities
from - to
from - to
If Yes, list courts, dates
9 Was decedent a party to any legal proceedings in New York State during the last five years?
Yes
No
and types of action.
10 Did decedent have a license to operate a business, profession, motor vehicle, airplane or boat?
Yes
No If Yes, list below.
License number
Type of license
Date of issuance
Name and location of issuing office
11 Did decedent execute any trust indentures, deeds, mortgages or any other documents
Yes
No If Yes, attach copy.
describing his or her residence during the last five years preceding death?
12 Was the decedent a member of any church, club or organization?
Yes
No
If Yes give name, address and other details.
(Attach additional sheets if necessary.)
13 What other information do you wish to submit in support of the contention that the decedent was not domiciled in New York State
at the time of death?
(Attach additional sheets if necessary.)
Applicant’s last name
First
Middle initial
Relationship to decedent
Address
Connection with estate
(number and street)
City, village or post office
State
ZIP code
The undersigned states that this affidavit is made to induce the Commissioner of the Department of Taxation and Finance of the State of New York to
determine domicile, and that the answers herein contained to the foregoing questions are each and every one of them true in every particular.
Notary Public, Commissioner of Deeds or Authorized New York State
Signature of applicant
Department of Taxation and Finance employee (no seal required)
Sworn before me this
day of
19
Signature
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