New York State Department of Taxation and Finance
                                                                                                            DTF-281
                                  Survivor’s Affidavit                                                                         (4/11) 
                                 Request for refunds under section 1310 SCPA
Note: We will not process your request unless you are a qualified recipient listed at line 2 and you enclose the refund check.

The State of New York, County of                                  :

                                                                  , being duly sworn, deposes and says that:
                      (Print name)

(1)  (S)he resides at                                                                 ,
     town
     village of                                         ,  in the county of
     city
     and the state of                                             , with the ZIP code                            .

(2)  (S)he is the:
         surviving spouse (Complete Part Iif you are submitting this affidavit pursuant to SCPA 1310(2). Complete Part  IIif you    
 (A)     are submitting this affidavit pursuant to SCPA 1310(3).) 
 (B)     child; 18 years or older (complete Part  )II  

 (C)     father or mother(complete Part II)

 (D)     brother or sister (complete Part II)

 (E)     niece or nephew(complete Part II)

of the decedent                                         (decedent’s social security number                                     )
                      (print name of deceased taxpayer)
who died on the                        day of                                          ,            .
                                                        (month)                          (year)
Part I
If box (A) is checked and this affidavit is being submitted pursuant to SCPA 1310(2), I attest that:
(1)  I am the surviving spouse of the decedent.

(2)  Probate of the decedent’s estate has not begun. No fiduciary of said estate has qualified or been appointed.

(3)  No designation of a beneficiary is in effect.

(4)  At the time of his/her death, there was due and owing to said decedent from the New York State Department of Taxation 
 and Finance, 

 the sum of                                             ($                 ) dollars

 for                                                               .

(5)  I make this affidavit to obtain payment to me of the sum of                                            ($                ) dollars 
 in full (or partial) satisfaction of the aforesaid debt due and owing to the decedent.

(6)  The payment requested herein and all payments received by me under the provisions of SCPA 1310(2) do not in the aggregate 
 exceed thirty thousand ($30,000) dollars.

                                                                                                                 2811110094

DTF-281 (4/11) (back)

Part II
If box (B), (C), (D), or (E) is checked, or if box (A) is checked and this affidavit is being made pursuant to SCPA section 1310(3), I attest that:
(1)  I am the                                                  of the decedent.
               (specify relationship to decedent)

(2)  Probate of the decedent’s estate has not begun. No fiduciary of the estate of said decedent has qualified or been appointed.

(3)  No designation of a beneficiary is in effect.

(4)  30 or more days have elapsed after the death of the decedent.

(5)  At the time of his/her death, there was due and owing to said decedent from the New York State Department of Taxation 
 and Finance, 

 the sum of                                                    ($               ) dollars

 for                                                              .                                                          

(6)  I make this affidavit to obtain payment in the amount of                                  ($                          ) dollars 
 in full (or partial) satisfaction of the aforementioned debt, which will be paid to the following named persons who are entitled to and 
 who will receive payment as follows (attach additional sheets if necessary):

               (name)                             (address including ZIP code)                            (amount)

               (name)                             (address including ZIP code)                            (amount)

               (name)                             (address including ZIP code)                            (amount)

               (name)                             (address including ZIP code)                            (amount)

(7)   The payment herein requested and all other payments made under the provisions of SCPA 1310 by all debtors known to me after 
 diligent inquiry made by me do not in the aggregate exceed the sum of fifteen thousand ($15,000) dollars.

                                                                  Signature

                                                                  Printed name

Subscribed and sworn to
                                                                                Mail this signed and notarized affidavit along with a 
before me this
                                                                                copy of the decedent’s death certificate to:
day of                 , 20
                                                                                NYS TAX DEPARTMENT
                                                                                RDOC-REFUND ISSUING UNIT
                                                                                W A HARRIMAN CAMPUS
                                                                                ALBANY NY 12227
        Notary Public - Commissioner of Deeds

                                                                                                          2812110094