New York & Federal Estate Tax Affidavit

NEW YORK & FEDERAL ESTATE TAX AFFIDAVIT

STATE OF NEW YORK ) ) COUNTY OF )

______being duly sworn and deposes and says:

I reside at ______

______

I am the (Executor-Administrator) of the Estate of ______who died a resident of ______County on ______

(If neither of the above, state relationship to decedent)

I am fully familiar with the assets of which the decedent died seized which comprise the gross estate as hereinafter defined, and the said gross estate is less than

$______and therefore, said estate is not subject to the Federal Estate Tax, or

New York Estate Tax.

I made this statement knowing full well that Chicago Title relies on the accuracy thereof for the purposes of issuing its policy of title insurance No. ______on premises known as ______

______

Sworn to before me this______day of ______, 20______