Affidavit in Support of Withdrawal of Funds Pursuant To SCPA $1310 (2) By a Spouse, Child, Mother, Father, Sister, Brother, Niece or Nephew

Collecting inherited money up to $15,000 by eligible relatives of the deceased person requires the execution of the following affidavit and the birth certificate of the deceased person. This has to take place no less than 30 days after the person’s death.

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ESTATE OFAFFIDAVIT IN SUPPORT OFWITHDRAWAL OF FUNDSPURSUANT TO SCPA §1310 (3)                                                                      BY A SPOUSE, CHILD, MOTHER, FATHEREnter the Decedent’s Full NameSISTER, BROTHER, NIECE OR NEPHEW  Deceased.                                                                        STATE OF                                         )           Choose Your State     )ss.:COUNTY OF                                     )I,                                                                     , being duly sworn, depose and say:                                                         Your Full NameA.I am a                                                          of                                                                                               Your Relationship to the Decedentalso known as                                                                                                                    ..                                                                                           Any Other Names the Decedent UsedB.A statement of heirs is attached to this affidavit.C.I reside at                                                                    ,                                                   Your Street Address                                                                         ,                                                 .                                                    City                                                                                                                 State                            Zip CodeD.                                                                       died on                                             , a                                                                                                                                                                                          Date of Deathresident of the State of New York as is shown on the original death certificate attached to thisaffidavit.E.More than thirty (30) days have elapsed since the decedent died.F.I hereby and request that you release to me all of the decedent’s personal property in your possessionand/or pay to me any and all funds standing in the name of the decedent pursuant to New York1

Surrogate’s Court Procedure Act §1310 (3), not to exceed the sum of $15,000.00.G.This payment and all other payments made under NY SCPA §1310 (3) by all debtors, known to me,after diligent inquiry, do not in the aggregate exceed $15,000.00.H.No Administrator, Executor or other fiduciary has qualified or been appointed to handle thedecedent's estate.I.A copy of the Surrogate’s Court Procedure Act §1310 is attached.J.I make this Affidavit in order to induce:                                                                                                  Name of Investment Firm, Bank, Agency, Insurance Co., etc in possession of the assetto release property or funds standing in the name of                                                                       (Account Number if applicable:                                                                                                       )                                                                                                                      Account or Policy Numbers, Etc.to me.                                                                        Sworn to before me this          day of                            ,                                                                    Notary PublicThis form is provided free of charge as a courtesy to the visitors ofwww.nycprobate.com. By using this form you acknowledge and accept the terms andconditions on the Web site and that you have read all instructions included with thisform and on the NEW YORK SMALL ESTATE AFFIDAVIT page. Copyright ©2014 Rudolf J. Karvay - All Rights Reserved. This form may not be reproducedwithout the permission of the author.2

Statement of Heirs - Claimant is the decedent’s spouse, child, mother, father, sister, brother, niece ornephew.Deceased:                                                                       Date of Death:                                                                                                                  , being duly sworn, deposes and says:1.  The decedent was:Single Married   Widowed       DivorcedIf the decedent was Single or was Divorced, skip to Section 4.2.  If the decedent was married and the spouse is alive, enter the spouse’s full name and address:NameAddress*A surviving spouse may claim up to $30,000 under SCPA §1310 (2) - click for Form 3.  If the decedent was widowed, enter the deceased spouse’s name, last address and date of death:NameAddressDate of Death4.  The decedent had:Children (living, deceased or adopted)Never had any ChildrenIf the decedent NEVER had children AND was never married or was divorced, skip to Section 7.5.  List the names, addresses and ages for all of the decedent’s living children:NameAddressAge*If there are additional living children, attach a separate sheet and check this box 3

If all of the decedent’s children are living, STOP you do not need to complete any further sections.6.  For each deceased child list the name, date of death and the names and addresses of his or her children(decedent’s grandchildren):NameDate of DeathA.Children of deceased Child ANameAddressAgeB.Children of deceased Child BNameAddressAgeC.Children of deceased Child CNameAddressAge*If there are additional deceased children, attach a separate sheet and check this box 4

Complete Section 7 only if the answers to Sections 2, 3, 5 and 6 were NONE.7.  A.  The decedent’s parents are:NameAddressLiving?Date of DeathFatherMotherB.  The decedent’s brothers and sisters (siblings) are:NameAddressLiving?Date of Death*If there are additional siblings , attach a separate sheet and check this box 5

If there are no deceased siblings, STOP - you need not complete any further sections.C.  The decedent’s nieces and nephews (list children of deceased siblings only) are:NameAddressLiving?Date of Death*If there are additional nieces and nephews , attach a separate sheet and check this box This statement was completed by                                                                      , who is related to thedecedent as a                                                                        , and who declares under penalty of perjury that theabove information is true and correct to the best of her/his knowledge.                                                                              Sworn to before me this          day of                            ,                                                                    Notary PublicCopyright © 2014 Rudolf J. Karvay - All Rights Reserved. Thisform may not be reproduced without the permission of the author.6

INSERT THE DECEDENT’S ORIGINALDEATH CERTIFICATE AND DISCARD THIS PAGE7

McKinney's SCPA § 1310§ 1310. Payment of certain debts without administrationEffective: October 3, 20111. As used in this section(a) “Debt” means (i) money or securities payable on account of a deposit in a bank, national bank, trust company, branch of aforeign banking corporation, savings bank, industrial bank, state or federal savings and loan association or stateor federal credit union or with a private banker, or funds or securities invested with, held by or deposited witha broker-dealer or with, by or in securities of a management type investment company or trust payable orreturnable to, or to the estate of, or to a beneficiary designated by, the depositor or(ii) money payable by a state or federal savings and loan association or state or federal credit union to, or to theestate of, or to a beneficiary designated by, a member on account of the withdrawal value of his shares or(iii) money payable by an insurance company or a savings bank authorized to conduct the business of lifeinsurance under an annuity or pure endowment contract or a policy of life, group life, industrial life or accidentand health insurance or a contract made by such an insurer, relating to the payment of proceeds or avails thereof,to, or to the estate of, or to a beneficiary designated by, the owner or the person purchasing the annuity or theperson insured or the person effecting the insurance or the person effecting the supplemental contract or(iv) money payable by a public corporation, a state or the federal government or an agency thereof, to, or to theestate of, or to a beneficiary designated by, any natural person or(v) a pension or retirement or death benefit, profit share, earnings, wages, salary or bonus payable by an employeror by a pension, retirement or profit-sharing plan or system to, or to the estate of, or to a beneficiary designatedby, an employee, or(vi) a balance of money due on an accepted claim or account payable, on account of dividends payable by thesuperintendent of financial services in liquidation of bank assets, to, or to the estate of, or to a beneficiarydesignated by, a depositor or(vii) any personal property deposited with a county treasurer by a coroner or county medical examiner pursuantto sections 785 and 786 of the code of criminal procedure,or(viii) any personal property on deposit with a hospital, nursing home, residential health care facility orout-patient lodge described in section twenty-eight hundred one of the public health law at the time of the deathof a decedent that is payable or returnable to the estate of the decedent;(b) “Debtor” means the person or persons, partnership, corporation, government or government agency by whoma debt defined in this section is to be paid,(c) “Creditor” means the employee, depositor, member, or other person, to whom, or to whose estate, or to abeneficiary designated by whom, a debt defined in this section is to be paid and shall include any beneficiaryvalidly designated by such a creditor, (d) A “designation of a beneficiary” means any writing, signed by the creditor and delivered to the debtorpurporting to designate the person to whom a debt shall be paid on death of the creditor or any transaction whichoperates pursuant to statute as such a designation. 2. Upon the death of a creditor, unless otherwise provided by a designation of a beneficiary which is then in effect,it shall be lawful for the debtor forthwith to pay to the surviving spouse of the decedent not more than thirtythousand dollars of the debt, upon an affidavit made by the spouse showing that the payment and all other8

payments received by the spouse under this subdivision do not in the aggregate exceed thirty thousand dollars.3. Not less than thirty days after the death of a creditor, unless otherwise provided by a designation of abeneficiary which is then in effect, it shall be lawful for the debtor to pay not more than fifteen thousand dollarsof the debt to(a) the surviving spouse,(b) one or more of the children eighteen years of age or older, (c) the father or mother,(d) the brother or sister, (e) the niece or nephew of the decedent, preference being given in the order named if request for payment shallhave been made by more than one such person, (f) a creditor of the decedent or to a person who has paid or incurred the funeral expense of the decedent, uponthe request of the surviving spouse or of one of such relatives. Payment under this subdivision may be made upon an affidavit by the surviving spouse or relative to whom orat whose request the payment is made, showing (i) the date of the death of the decedent, (ii) the relationship of the affiant to the decedent, (iii) that no fiduciary has qualified or been appointed, (iv) the names and addresses of the persons entitled to and who will receive the money paid, and(v) that such payment and all other payments made under this section by all debtors, known to the affiant, afterdiligent inquiry do not in the aggregate exceed fifteen thousand dollars. This subdivision does not limit the rightof a debtor to make payment to a surviving spouse within less than thirty days after the death of the creditor asprovided in subdivision two.4. Not less than 6 months after the death of a creditor, unless otherwise provided by a designation of a beneficiarywhich is then in effect, it shall be lawful for the debtor to pay a debt which does not exceed $5,000, or any partof such debt, to a distributee or, to the extent that the funds are not exempt from claims of creditors, to a creditoror to a person who has paid or incurred the funeral expenses upon an affidavit made by the person paid showing(a) the date of the death of the decedent,(b) that no fiduciary has qualified or been appointed, (c) that the decedent was not survived by a spouse or minor child,(d) that the affiant is entitled to the payment, and (e) that such payment and all other payments made under this section by all debtors, known to the affiant, afterdiligent inquiry, do not in the aggregate exceed $5,000. 5. A payment made in good faith under this section shall be a complete discharge to the debtor to the extent ofthe payment, even though the affidavit on which payment is made be false, and even though payment pursuantto subdivision 3 was not made in the order of preference indicated in that subdivision, provided only that thecreditor be dead and that the required number of days elapse between death and payment and, in the case of apayment under subdivision 2 or subdivision 3 that the affiant in fact bear the stated relationship to the decedentand in the case of a payment under subdivision 4 that the affiant be in fact a distributee or creditor or have paid9

or incurred the funeral expenses.6. Any person receiving payment pursuant to this section is accountable therefor to the fiduciary of the decedentif one be appointed or to the public administrator of the county having authority to take possession of the moneyor property constituting the debt except that a surviving spouse entitled to have property set aside to him or toher pursuant to EPTL 5-3.1 need not account for such payments to the extent of the exemption provided therein,and the amount so received shall be credited to such exemption.7. Nothing in this section shall deprive any person of any right which he would otherwise have to receive paymentof a debt, except as against a debtor who has made a payment which is a discharge under subdivision 5, nor shallanything in this section deprive any debtor of any right to make or refuse payment which it would otherwise have.This section does not limit article 26 of the tax law.8. It shall be lawful for the debtor to pay a debt which does not exceed five thousand dollars or any part of suchdebt, under subdivision four of this section, to the department of social services or a social services district wherethe debt is money payable on account of a deposit with the debtor for the personal needs of the deceased creditorwhile residing in a medical institution or other facility, or otherwise, and the deceased creditor is indebted to thedepartment or district on account of medical assistance furnished to or on behalf of the deceased creditor. 9. This section applies only to creditors who die on or after September 1, 1952.10

INSTRUCTIONSNew York law, SCPA §1310, permits certain relatives and creditors to collect the decedent’sassets without going to court.  The law requires that an affidavit be presented with specificinformation.You should prepare a separate affidavit for each bank, brokerage house, insurance company oragency holding money or property. Once you have completed the free affidavit we provided, take the following steps:1. Print the completed document.2.Sign the Affidavit AND the Statement of Heirs before a Notary Public. 3.Attach the decedent’s original death certificate as page 7.4.Make sure the statute (SCPA 1310) remains attached to the affidavit.5.Send the original affidavit and a cover letter from you to                                                                                                     by certified mail, returnreceipt requested.  You may use another delivery method, but make sure that delivery isverifiable.6.If you do not hear from the financial institution within a reasonable time, call them tofollow up.  Note: it is up to the financial institution to honor this request.! DISCARD THIS PAGE BEFORE MAILING THE AFFIDAVIT AND ITS ATTACHMENTS !