<p> NEW YORK & FEDERAL ESTATE TAX AFFIDAVIT</p><p>STATE OF NEW YORK ) ) COUNTY OF )</p><p>______being duly sworn and deposes and says:</p><p>I reside at ______</p><p>______</p><p>I am the (Executor-Administrator) of the Estate of ______who died a resident of ______County on ______</p><p>(If neither of the above, state relationship to decedent)</p><p>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</p><p>$______and therefore, said estate is not subject to the Federal Estate Tax, or</p><p>New York Estate Tax.</p><p>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 ______</p><p>______</p><p>Sworn to before me this______day of ______, 20______</p>