Department of Taxation and Finance

                                       Survivor’s Affidavit                                                 DTF-281 (4/20) 
                                       Request for refunds under SCPA section 1310

Note: We will not process your request unless you are a qualified recipient listed on 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(mark an  Xin the appropriate box):
              surviving spouse (Complete Part 1 if you are submitting this affidavit pursuant to SCPA 1310(2). Complete Part 2 if you    
      (A)     are submitting this affidavit pursuant to SCPA 1310(3).) 
     (B)      child; 18 years or older (complete Part 2) 

     (C)      father or mother (complete Part 2)

     (D)      brother or sister (complete Part 2)

     (E)      niece or nephew (complete Part 2)

of the decedent                                          (decedent’s Social Security number                                   )
                       (print name of deceased taxpayer)
who died on the                                day of                        ,                     .
                                                         (month)                             (year)

Part 1
If box (A) is marked 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.

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Page 2 of 2    DTF-281 (4/20) 

Part 2
If box (B), (C), (D), or (E) is marked, or if box (A) is marked 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)            (Social Security number)             (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
                                                                               PSSB-REFUND ISSUING UNIT
                                                                               W A HARRIMAN CAMPUS
                                                                               ALBANY NY 12227-0125
            Notary Public - Commissioner of Deeds

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