STATE OF NEW YORK

COUNTY OF [County Name]

Introduction:

I, [YOUR NAME], being duly sworn, depose and say that:

Statement of Facts:

1. The decedent, [Decedent's Name], passed away on [Date], in [Decedent's Address], New York. At the time of their passing, the decedent resided at [Decedent's Last Residential Address].

2. This affidavit is being made to address the matters concerning the decedent's estate and to assist in the appropriate distribution of assets according to New York state laws.

3. I am the [relationship to the decedent], and my address is [YOUR ADDRESS]. I have personal knowledge of the decedent’s family history and make this affidavit to identify the heirs entitled to the estate of the decedent.

4. The decedent was [married/unmarried/widowed/divorced] at the time of death.

   • The names and relationships of the decedent's surviving relatives are as follows:

     • Spouse: [Name]

     • Children: [Name]

     • Parents: [Name]

     • Siblings: [Name]

5. The decedent died owning the following assets that require the execution of this affidavit for transfer or distribution:

   • The assets include a savings account located at [Bank Name]

   • Account number [Account Number] and a brokerage account with [Investment Name]

   • Account number [Account Number].

   • These accounts are part of the estate and will be managed according to the terms outlined in the decedent's will.

6. Based on the information provided, the following individuals are the rightful heirs to the decedent's estate under New York law:

   • [Heir #1: Name, Relationship, Share of Estate]

   • [Heir #2: Name, Relationship, Share of Estate]

Declarations:

To the best of my knowledge, the total value of the decedent's personal property does not exceed the amount specified under New York law for small estates.

There are no pending applications or petitions for the appointment of a personal representative for the decedent's estate in New York or any other jurisdiction.

I swear under penalty of perjury that the foregoing is true and correct to the best of my knowledge, belief, and understanding.

Executed on this [DAY] of [MONTH], [YEAR].

Signature:

[YOUR NAME]

[NOTARY PUBLIC NAME]

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