Form Et-141 - New York State Estate Tax Domicile Affidavit
ADVERTISEMENT
1
2New York State Department of Taxation and Finance
ET-141
New York State Estate Tax Domicile Affidavit
(1/15)
For estates of decedents dying after May 25, 1990
Complete Form ET-141 if it is claimed that the decedent was not domiciled in New York State at the time of death.
The fiduciary (executor or administrator), the surviving spouse, or a member of the decedent’s immediate family who can provide
all the information requested below should complete this affidavit.
Answer all questions completely. Submit this form with Form ET-30; ET-85; ET-90 for dates of death before February 1, 2000; ET-130;
ET-133; or ET-706 for dates of death on or after February 1, 2000; as applicable.
Decedent’s last name
First
Middle initial
Social security number
Address of decedent at time of death
Date of death
(number and street)
City, village or post office
County
State
ZIP code
Country of residence
Age of death
Date of birth
Place of birth
1 If born outside the United States, was the decedent a naturalized citizen of the United States?
If Yes, enter (below) the name and address of the court where the decedent was naturalized.
Yes
No
Name and address of court where naturalized
2 Did decedent ever live in New York State?
If Yes, list periods.
Yes
No
3 Did decedent ever own, individually or jointly, any
interest in real estate located in New York State?
Yes
No
If Yes, list addresses and periods below
.
(submit additional sheets if necessary)
Periods of time - from/to
Addresses of property
4 Did decedent lease a safe deposit box located in New York State at the time of death?
Yes
No
If Yes, submit a copy of inventory.
If Yes, complete box below. Also, if Yes, has it been inventoried?
Yes
No
Name and address of bank where box is located
5 Provide the following information regarding the residences of the decedent during the last five years preceding death
.
(submit additional sheets if necessary)
Period of time
Period of time
Residence
Residence
owned - rented
owned - rented
Address
Address
from - to
from - to
other - explain
other - explain
6 For the five years prior to death, list (1) the Internal Revenue Service Centers and (2) the states or other municipalities where the
decedent filed income tax returns
(if no income tax returns were filed, enter none)
.
Year
Internal Revenue Service Center
State, county, or municipality
Privacy notification
New York State Law requires all government agencies that maintain a system of records to provide notification of the legal authority for any
request, the principal purpose(s) for which the information is to be collected, and where it will be maintained. To view this information, visit our
Web site, or, if you do not have Internet access, call and request Publication 54, Privacy Notification. See Need help? for the Web address
and telephone number.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial