INSTRUCTIONS: This form, along with the title or transferable registration properly completed, may be used to transfer a motor vehicle having a
value of twenty-five thousand dollars ($25,000) or less , owned by a person at the time of his/her death, to a surviving spouse or child or
children under the age of twenty-one years. It may also be used to transfer such a motor vehicle to another party for the benefit of a surviving
spouse or child or children under the age of twenty-one years. A COPY OF THE DEA TH CERTIFICA TE (CERTIFICA TE OF DEA TH OR
CERTIFICA TION OF DEA TH) MUST BE PROVIDED . State of New Y ork )____________________________________________________________________________________, being duly sworn, deposes and says:
1. (a) I am the surviving spouse of ____________________________________________________________________________________
(b) I am the duly appointed guardian of ______________________________________________________________________________,
the surviving minor child or children of ______________________________________________________________________________.
2. The said ___________________________________ died on the _________ day of ____________________, in the year of ____________.
3. At the time of his/her death, the said ___________________________________________________________________was the owner of a
______________ _____________ _______________ _____________________________ _____________________V ehicle identification or serial number ___________________________________________________________.
4. The name of the person to whom the vehicle is being transferred is ________________________________________________________
5. Check one of the following:o The above mentioned motor vehicle has a value of not more than twenty-five thousand dollars ($25,000) .
o The above mentioned motor vehicle has a value which exceeds $25,000, but pursuant to Estates, Powers and T rusts Law §5-3.1(a)(4),
I have paid to the estate the sum of $____________, the amount by which the value of such motor vehicle exceeds $25,000.
6. The above mentioned motor vehicle is the only motor vehicle belonging to the decedent that is being transferred under Section 5-3.1 of the
Estates, Powers and T rusts Law.7. The deponent is a person qualified to take said motor vehicle under Section 5-3.1 of the Estates, Powers and T rusts Law, and hereby
makes claim to said motor vehicle.8. The deponent is not a disqualified spouse under Section 5-1.2 of the Estates, Powers and T rusts Law , and hereby makes claim to said
motor vehicle. (See page 2.)9. This affidavit is made for the purpose of securing a transfer of the above mentioned motor vehicle under the provisions of Section 5-3.1 of
the Estates, Powers and T rusts Law. ç _________________________________________________________________Sworn to before me this _______day of _________________________________________, in the year of _______________.
__________________________________________________________ My Commission expires__________________________________
