Fill and Sign the New York Estate 497321671 Form

SURROGATE’S COURT OF THE STATE OF NEW YORK COUNTY OF __________________________ ----------------------------------------------------------------------------X AFFIDAVIT IN RELATION TO VOLUNTARY ADMINISTRATION, Estate of SETTLEMENT OF ESTATE UNDER ARTICLE 13, SCPA _______________________________________, File No. ________________________________ (as of 1/2009)* Deceased. ---------------------------------------------------------------------------X (INSTRUCTIONS: In completing this form, STATE OF NEW YORK ) answer each question. This may be done in some instances by crossing out words COUNTY OF ____________________________) ss.: in parentheses and in some instances by inserting the required information.) I, ___________________________________________________________________, being duly sworn, depose and say (1) My permanent address is: __________________________________________________________________________ (Street Address) (City/Town/Village) _______________________________________________________________________________________________ (County (State) (Zip) (Telephone Number) My mailing address is: ______________________________________________________________________________ (If different from permanent address ) (2) My interest is: [ ] Distributee of decedent _______________________________________________________ (Relationship) [ ] Other (Specify) _____________________________________________________________ (3) The name, permanent address, date, place of death, and citizenship of the decedent, to whose estate this proceeding relates, are as follows: Name of Decedent (a/k/a, if applicable): __________________________________________________________________ Permanent Address: _________________________________________________________________________________ (Street Address) (City/Town/Village) (County) (State) Date of Death: ___________________________Place of Death: _____________________________________________ (City/Town/Villag e) (State) Citizenship: _________________________________ (4) Decedent died: [ ] Intestate (without a will) [ ] Testate (the original will is attached) (5) A search of the records of the Court shows that no application has been made in the estate of the decedent for voluntary administration, letters of administration or for probate of a will, and your affiant is informed and verily believes that no such application ever has been made to any other Surrogate’s Court in this state. SE-3A *For use only where decedent died on or after January 1, 2009 SE-3A -1- (6) The names and addresses of the decedent’s distributees under New York law, including non-marital children and descendants of predeceased non-marital children, and their relationships to the decedent, are as follows: (If more space is needed, add a sheet of paper) Post Office Relationship Name Address (Including Zip) Indicate if non-marital) _____________________ ____________________________ _________________________ _____________________ ____________________________ _________________________ _____________________ ____________________________ _________________________ (7) (If decedent had a will) The names and addresses of all beneficiaries in the will of the decedent filed herewith are as follows: (If more space is needed, add a sheet of paper) Post Office Name Address (Including Zip) Bequest _____________________ ____________________________ __________________________ _____________________ ____________________________ ___________________________ _____________________ _____________________________ ___________________________ 8) The value of the entire personal property, wherever located, of the decedent, exclusive of joint bank accounts, trust accounts, U.S. savings bonds POD (payable on death), and jointly owned personal property, or property exempt under the EPTL §5-3.1, does not exceed $30,000.00. 9) The following, exclusive of joint bank accounts, trust accounts, U.S. savings bonds POD (payable on death), and jointly owned personal property, or property exempt under EPTL §5-3.1, is a complete list of all personal property owned by the decedent, either standing in his/her own name or owned by him/her beneficially and including items of value in any safe deposit box. (If more space is needed, add a sheet of paper) Items of Personal Property Separately Listed Value of Each Item ___________________________________________ _____________________________ ___________________________________________ _____________________________ ___________________________________________ _____________________________ TOTAL $ -2- (10) All the liabilities of the decedent known to me are as follows: (If more space is needed, add a sheet of paper) Name of Creditor Amount Owed __________________________________ ____________________________ __________________________________ _____________________________ __________________________________ _____________________________ (11) I undertake to act as voluntary administrator of the decedent’s estate, and to administer it pursuant to Article 13 of the Surrogate’s Court Procedure Act. I agree to reduce all of the decedent’s assets to possession; to liquidate such assets to the extent necessary; to open an estate bank account in a bank of deposit or savings bank in this state, in which I shall deposit all money received; to sign all checks drawn on or withdrawals from such account in the name of the estate by myself, as voluntary administrator; to pay the expenses of administration, the decedent’s reasonable funeral expenses and his/her debts in the order provided by law; and to distribute the balance to the person or persons and in the amount or amounts provided by law. As voluntary administrator, I shall file in this court an account of all receipts and of disbursements made. (12) I understand that this proceeding will not determine the estate tax liability, if any, in the event that the decedent had any interest in real property or any joint bank accounts, trust accounts, U.S. savings bonds POD (payable on death), or jointly owned or trust property. (13) If letters testamentary or of administration are later granted, I acknowledge that my powers as voluntary administrator shall cease, and I shall deliver to the court-appointed fiduciary a complete statement of my account and all assets and funds of the estate in my possession. ________________________________ Signature of Affiant _________________________________ Print Name Sworn to before me on _________________________, 20 _____ _________________________________ Notary Public My Commission Expires: (Affix Notary Stamp or Seal) Signature of Attorney: ________________________________________________________________________________ Print Name: _______________________________________________________________________________________ Firm Name: _________________________________________________Tel. No.: ______________________________ Address of Attorney: ________________________________________________________________________________ -3-