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CJS Land Services, Inc. COMBINED FEDERAL ESTATE TAX AND NEW YORK STATE ESTATE TAX AFFIDAVIT (Decedent’s Death After 2/1/2000) Title No. ________________ Premises: _______________ _______________________ STATE OF NEW YORK ) COUNTY OF _____________ ) SS.: ____________________________________, being duly sworn 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. The value of the decedent’s gross Federal estate, as defined by the Internal Revenue Code, is less than $ _____________, and therefore the decedent’s estate is not subject to Federal Estate Tax or New York Estate Tax. (Delete reference to New York Estate Tax if amount is greater the exempt amount set forth on the Notes on reverse side.) I make this statement knowing full well that ___________________Title Insurance Company and its agent CJS Land Services, Inc. are relying on the truth of the statements herein for the purposes of issuing its policy of title in the captioned matter. _____________________________ Sworn to before me this ____________ day of _______________, 20____.
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