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	New York State Department of Taxation and Finance	TT-141A
	Estate Tax Domicile Affidavit	TT-141A
	Estate Tax Domicile Affidavit	(1/03)

For the estate of an individual who died after December 31, 1982, and before May 26, 1990

If it is claimed that the decedent was not a New York State resident 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.

Note – If this affidavit is filed with New York State Form TT-86.5, omit questions 28 through 33.

If the estate is filing Form TT-385, New York State Estate Tax Return, or the date of death is on or after May 26, 1990, use Form ET-141, New York State Estate Tax Domicile Affidavit, instead.

If the estate filed a federal estate tax return, Form 706 or 706-NA, attach a copy. Answer all questions completely.

This affidavit must be notarized on page 4.

Decedent’s last name

First name

Initial

Age at

Date of death (attach

Decedent’s social security number

death

death certificate)

Decedent’s domicile

Address

County

State

Country

Attorney for estate (if any)

Name

Address

Telephone number

Applicant’s name

2 Applicant’s address and telephone number

Applicant’s relationship to decedent

or connection with estate

Decedent’s date of birth

Decedent’s place of birth

5a If born outside the U.S., was decedent a naturalized citizen of the United States?

Yes

If 5a is Yes, give court and location where naturalized

If decedent was a U.S. Citizen, did he or she ever apply for a passport? If Yes, give dates of application and

renewals and decedent’s address as it appears on the passport.

Yes

7 Decedent’s occupation (if retired, so state and give former

8 Name and address of employer (if retired, former employer)

occupation)

Was decedent ever married?

9a If Yes, give date and place of marriage

Name and address of spouse

Yes

If Yes, give name, address, and other details. (attach separate sheet if necessary)

11 Was decedent a member of any church, club, or organization?

Yes

Did decedent leave a will?

13 Name and address of executor or administrator of decedent’s estate (attach copy of certificate of appointment).

Yes

If no fiduciary appointed, write none.

(if Yes, attach copy)

14 Name and address of court where will was or is to be probated, or estate administered

15 Did decedent execute any other wills during

the last five years preceding death?

Yes

(if Yes, attach copy)

Did decedent ever live in New York State?

16a

If Yes, for what periods?

17 Provide the following information regarding the residence(s) of the decedent during the last five years preceding death:

In New York State

Outside New York State

Residence

Period of time

owned - rented

Period of time

owned - rented

from – to

Address

other (explain)

from - to

Address

other (explain)

Page 2 of 4 TT-141A (1/03)

Did decedent ever own real estate located in

18a Period of time

18b Address of property

New York State?

from - to

Yes

(If Yes, complete items 18(a) and (b))

In what state(s) did decedent vote or register to vote during the five years preceding death? (show latest year first)

Year

State

If decedent did not vote in those five years, where did he last vote?

20a When did decedent last vote?

Did decedent execute any trust indentures, deeds, mortgages, leases, or any other documents describing his residence during the last five years preceding death?

Yes

If so, attach copy

Did decedent own a safe deposit box

22a

If Yes, has it been inventoried?

22b Name and address of bank where box is located.

located in New York State?

Yes

If Yes, attach a copy

Was decedent a party to any legal proceedings in the state of New York during the last five years of his or her life?

If Yes, list the court or tribunal, or other forum, and the date, and type of action.

Yes

Did decedent have licenses to operate a business, practice a profession, or operate a motor vehicle, airplane, or boat?

If Yes, give information requested below.

Yes

License number

Type of license

Date of issuance

Name and location of issuing office

List the Internal Revenue Service Center, and the state, county, and municipality where decedent filed income tax returns and paid tax on income or

intangible personal property for the last five years preceding death. (Income tax returns (federal and state) may be required.)

Year

Internal Revenue Service Center

State, county, or municipality

Give detailed information about business activities (if any) engaged in by the decedent during the five years preceding date of death

In New York State

Outside New York State

Dates

Nature of business activities

Dates

Nature of business activities

TT-141A (1/03) Page 3 of 4

27What other information do you wish to submit in support of the contention that the decedent was not domiciled in the state of New York at the time of death?

28List below, at total value, any real property, tangible personal property, or intangible personal property wherever located in which the decedent had an interest at death, and taxable transfers made by the decedent within three years of decedent’s death (included in federal gross estate).

(amounts should be taken from federal Form 706)

Real property	$
Tangible personal property	$
Intangible personal property	$
Transfers within three years of death	$
Gift tax paid on gifts made after	$
6/30/78 and within three years of death

Total $

29 Did the decedent at time of death own, individually or jointly, any interest in real property in New York State?

Yes

No	If Yes, and Release of Lien is desired, please supply the following information:
	(complete question 30 also)

Book of Deeds or Liber No.

at page no.

map no.

section no.

block no.

lot no.

Property address

Street or road

City, town, or village

30Show assessed and market value (and balance owed on mortgage, if any), of real property described in question 29. (real estate appraisal may be required)

(a) Assessed value - $		(b) Market value - $		(c) Balance owed on mortgage, if any - $
				(submit proof of indebtedness)

31Did decedent own any tangible personal property, such as household furnishings, jewelry, coin collections, paintings, boats, automobiles, etc., having an actual situs in New York State?

Yes

No	If Yes, describe in detail.

Item

Address where item is located

Market value

32List below the securities, bank accounts, or other intangible property for which tax waivers are requested.

Name of bank; name of corporation or association issuing stocks and bonds; name of government issuing government bonds; name of insurance company

Amount of account; number of shares of stock; face value of bonds; amount of policy or annuity

Description of stocks or bonds; series of government bonds; kind of policy or annuity

Name(s) on bank account; name(s) on stocks or bonds; name and address of beneficiary or annuitant

(attach additional sheets, if necessary)

Page 4 of 4 TT-141A (1/03)

Complete items 33, 34, and 35 only if decedent owned real or tangible personal property having an actual situs in New York State. (Affirmation section must be completed.)

33 Computation of New York gross estate and taxable estate

35 Computation of nonresident tax

(a) Federal gross estate*

Items 30(b) + 31

× Item 34(f) = New York State

Item 33(c)

nonresident tax

(b) Less real + tangible personal

–

property located outside NYS

(complete Schedule I below)

Schedule I — Real and/or tangible personal property located outside

(d) Less:

Funeral expense

New York State. (Do not include bank accounts, stocks, bonds, etc.) (Complete this

schedule if item 33, line (b), is used.)

Mortgage (amount entered

in item 30(c)**)

–

Total

(e) New York adjusted gross estate

(f) Less:

New York marital deduction**

New York charitable bequests**

–

Total

(g) New York taxable estate (enter in item 34(a))

* A copy of federal Form 706 may be required.

** if applicable

Note: If additional adjustments to federal gross estate are necessary, e.g.,

34 Tax computation as if a resident

gifts made prior to 1983 or qualified terminable interest property included in

(a) New York taxable estate (from item 33(g))

line 33(a), attach separate sheet showing such adjustments.

Schedule II — Bequests, etc. to surviving spouse (complete this schedule if a

(b) Plus adjusted New York taxable gifts

marital deduction is claimed in item 33 line (f)) If entire estate passes to surviving

made after 1982

spouse, write entire estate.

(d) New York tentative estate tax

(compute on amount shown on line (c); see Table A)

(e) Less: Unified credit (see Table B)

New York gift tax payable on

amount shown on line (b)

–

Total

(f) New York net estate tax, as if a resident

The undersigned states that the foregoing sets forth all of the assets constituting the decedent’s gross estate, and the answers to the foregoing questions are each and everyone true in every particular, and that this affidavit is made to induce the Commissioner of Taxation and Finance to determine domicile, to give a waiver notice and/or release of lien required by the Tax Law of the State of New York.

Fiduciary or applicant — sign here

Sworn before me this	day of		, 20	,
in the County of				,
in the State/Commonwealth/Province of				.
Qualified in the County of		. Commission expires on	, 20	.

(Notary Public, Commissioner of Deeds or Authorized New York State Department of Taxation and Finance employee)

• Attach authentication certificate if this affidavit is sworn to in a foreign country.

Note: Disclosure of social security number is required. Such numbers are used for tax administration purposes and as necessary pursuant to Education Law, sec. 663; Social Services Law, sec. 111b and 136a; and Executive Law, sec. 49; and Tax Law, sec 171b, and when the taxpayer gives written authorization to this department for another department, person, agency, or entity to have access, limited or otherwise, to information contained in his or her return.

Notice — Section 1811(b) of the Tax Law provides that any person who, with intent to evade taxation, files a false or fraudulent return, supplies false or fraudulent information, or withholds material information with intent to deceive, shall be guilty of a misdemeanor.

Table A – Tax table — If the amount with respect to which the tax is to be computed is:

Over		But not over		The tax is:

$	0	$	50,000				2% of such amount
	50,000		150,000	$	1,000	+	3% of excess over $	50,000
	150,000		300,000		4,000	+	4% of excess over	150,000
	300,000		500,000		10,000	+	5% of excess over	300,000
	500,000		700,000		20,000	+	6% of excess over	500,000
For amounts over $700,000 refer to instructions TT-86.5-I (3/90) page 10, Table A, or TT-102-I (1/94) page 4, Table A.
		Table B – Unified credit — If the tentative tax is:

Over		But not over				The credit is:

$	0	$	2,750			the full amount of tax
	2,750		5,000			the amount by which $5,500 exceeds the tax
	5,000					$500

Question	Answer
Form Name	Form Tt 141A
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	tt141a_103 tt 141a form

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