Free affidavit of domicile 14Free affidavit of domicile 14
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New York State Department of Taxation and Finance

ET-141
(1/15)

New York State Estate Tax Domicile Affidavit
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)
City, village or post office
Age of death

Date of death

County

Date of birth

State

ZIP code

Country of residence

Place of birth

1 If born outside the United States, was the deced