New York Codes, Rules and Regulations
Title 22 - JUDICIARY
Subtitle D - Forms
Chapter VII - Surrogate's Court Forms
Subchapter A - Forms Authorized By Section 207.52
Surrogate's Forms
Form SE1A - Affidavit in relation to settlement of estate
THE CERTIFIED COPY MUST BE RETAINED BY THE VOLUNTARY
ADMINISTRATOR/TRIX FOR FILING WITH THE REPORT AND ACCOUNT
SURROGATE'S COURT OF THE STATE OF NEW YORK
COUNTY OF ________
________X
VOLUNTARY ADMINISTRATION, Estate of AFFIDAVIT IN RELATION
TO SETTLEMENT OF
________, ESTATE UNDER
ARTICLE 13, SCPA
Deceased File No. ________
________X
STATE OF NEW YORK) [INSTRUCTIONS: In completing this form, answer
ss.: each question. This may be done in some instances
COUNTY OF ________) by crossing out words in parentheses, and in other
instances by inserting the required information.]
I, ____________, being duly sworn, depose and say:
(1) My domicile is ____________
(Street address) (City/Town/Village)
____________
(County) (State) (Zip) (Telephone Number)
My mailing address is ____________
(if different from domicile)
(2) My interest is: [ ] Distributee of decedent ____________
(Relationship)
[ ] Other (Specify) ____________
(3) The name, domicile, 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):____________
Domicile of Decedent: ____________
(Street address) (City/Town/Village) (County) (State)
Date of Death:____________ Place of Death: ____________
(City/Town/Village) (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 of this state.
(6) The names and addresses of the decedent's distributees under New York law, including non-marital children, and decendants of predeceased non-marital children, and their relationship 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
____________
____________
____________
____________
____________
(I) [FN3] ( ____________ and I jointly and severally) undertake that defendant will appear in§5-3.1, does not exceed $10,000.00.
(I) [FN3] ( ____________ and I jointly and severally) undertake that defendant will appear in§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 Space for Endorsements
Separately Listed Value of Each Item By Transferors
____________
____________
____________
____________
____________
________
TOTAL: $
(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/trix 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 withdrawls from such account in the name of the estate by myself, as voluntary administrator/trix; 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/trix, I shall file in this court an account of all receipts and of disbursements made.
(I) [FN3] ( ____________ and I jointly and severally) undertake that defendant will appear in
(13) If letters testamentary or of administration are later granted, I acknowledge that my powers as voluntary administrator/trix 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
________, 19________.
______________
Notary Public
My Commission Expires: ________
NAME OF ATTORNEY: ____________
ADDRESS: ____________
TELEPHONE NUMBER: ________
