New York State Department of Taxation and Finance
                                                                                                                                ET-141
                New York State Estate Tax Domicile Affidavit                                                                                    (1/15)
                For estates of decedents dying after May 25, 1990
Complete Form ET-141 if it is claimed that the decedent was not domiciled in New York State at the time of death.
The fiduciary (executor or administrator), the surviving spouse, or a member of the decedent’s immediate family who can provide 
all the information requested below should complete this affidavit.

Answer all questions completely. Submit this form with Form ET-30; ET-85; ET-90 for dates of death before February 1, 2000; ET-130; 
ET-133; or ET-706 for dates of death on or after February 1, 2000; as applicable.
Decedent’s last name                                   First                                    Middle initial            Social security number

Address of decedent at time of death (number and street)                                                                  Date of death

City, village or post office                   County                                     State  ZIP code                 Country of residence

Age of death     Date of birth              Place of birth

 1  If born outside the United States, was the decedent a naturalized citizen of the United States?
      If Yes, enter (below) the name and address of the court where the decedent was naturalized.              Yes            No
 Name and address of court where naturalized

 2  Did decedent ever live in New York State?  Yes        No     If Yes, list periods.
 3  Did decedent ever own, individually or jointly, any
      interest in real estate located in New York State?  Yes    No                  If Yes, list addresses and periods below (submit additional sheets if necessary).
 Periods of time - from/to                  Addresses of property

  4  Did decedent lease a safe deposit box located in New York State at the time of death?       Yes           No
       If Yes, complete box below. Also, if Yes, has it been inventoried?    Yes            No         If Yes, submit a copy of inventory.
 Name and address of bank where box is located

  5 Provide the following information regarding the residences of the decedent during the last five years preceding death (submit additional sheets if necessary).

 Period of time                                                  Residence   Period of time                                            Residence
    from - to                Address                         owned - rented  from - to                         Address                 owned - rented
                                                             other - explain                                                           other - explain

  6 For the five years prior to death, list (1) the Internal Revenue Service Centers and (2) the states or other municipalities where the    
       decedent filed income tax returns (if no income tax returns were filed, enter none).
   Year                      Internal Revenue Service Center                                     State, county, or municipality

                                                                 Privacy notification
New York State Law requires all government agencies that maintain a system of records to provide notification of the legal authority for any 
request, the principal purpose(s) for which the information is to be collected, and where it will be maintained. To view this information, visit our 
Web site, or, if you do not have Internet access, call and request Publication 54, Privacy Notification. See Need help? for the Web address 
and telephone number.

ET-141 (1/15) (back)

  7  List the states where the decedent was registered to vote during the last five years preceding death (list latest year first).
                              Years                                                                     State
                From                                  To
                                                 Date of Death

If decedent did not vote in those five years, when did he or she last vote?                             Where?

  8  List employment or business activities (if any) engaged in by the decedent during the five years preceding the date of death.
                              In New York State                                               Outside New York State
 Period of time                                                           Period of time
    from - to                 Nature of employment or business activities   from - to         Nature of employment or business activities

                                                                                                                                   If Yes, list courts, dates,
 9  Was decedent a party to any legal proceedings in New York State during the last five years?         Yes   No                   and types of action.
                                                                                                                  
 10 Did decedent have a license to operate a business, profession, motor vehicle, airplane, or boat?  Yes     No                   If Yes, list below.
      License number          Type of license    Date of issuance                             Name and location of issuing office

 11 Did decedent execute any trust indentures, deeds, mortgages, or any other documents
       describing his or her residence during the last five years preceding death?                      Yes   No                   If Yes, submit a copy.
 12 Was the decedent a member of any church, club, or organization?         Yes        No
       If Yes, give name, address, and other details. (Submit additional sheets if necessary.)

 13 What other information do you wish to submit in support of the contention that the decedent was not domiciled in New York State at the  
       time of death? (Submit additional sheets if necessary.)

Applicant’s last name                                 First name                         Middle initial    Relationship to decedent

Address (number and street)                                                                                Connection with estate

City, village, or post office                         State                                   ZIP code     Country of residence

The undersigned states that this affidavit is made to induce the Commissioner of the Department of Taxation and Finance of the State of New York to determine 
domicile, and that the answers herein contained to the foregoing questions are each and every one of them true in every particular.
                                                                          Signature of Notary Public, Commissioner of Deeds or Authorized New York State  
Signature of applicant                                                    Department of Taxation and Finance employee (no seal required)

Sworn before me this          day of                          20 
                                                                          Signature