DECEDENT ESTATE - ALTERNATIVE AFFIDAVIT

DEMONSTRATING NO REQUIREMENT FOR IRS TRANSFER CERTIFICATE

TO BE USED ONLY IF DECEASED WAS (1) NONRESIDENT, (2) NOT A CITIZEN OF THE
U.S., AND (3) DID NOT OWN “U.S. SITUS” ASSETS EXCEEDING $60,000

CITY (Town) of )

STATE of )

COUNTRY of )

___________________________________, BEING DULY SWORN, DEPOSES AND SAYS:

(Name of Deponent)

1. I AM OVER THE AGE OF TWENTY-ONE YEARS AND RESIDE AT

__________________________________________________________________________________________
_________________________________________________________________________________________.

2. THE DECEDENT _____________________________________________________________

(Name of Decedent)
DIED ON THE ________________________ DAY OF _________________________, 19 _____________,
(Day) (Month) (Year)
AT WHICH TIME THE LEGAL DOMICILE OF SAID DECEDENT WAS AT

_____________________________, CITY OF __________________________________ COUNTRY OF

(Street Address) (City or Town)
__________________________________________. FOR AT LEAST TWO YEARS PRIOR TO HIS/HER
(Country)
DEATH THE DECEDENT DID NOT RESIDE IN NEW YORK STATE NOR ANYWHERE IN THE

UNITED STATES.

3. THE DECEDENT WAS BORN AT _______________________________________________

(Place of Birth - City and Country)
ON ______________________________.
(Date - Day and Year)

4. THE DECEDENT WAS NEVER A CITIZEN OF THE UNITED STATES OF AMERICA AND

NEVER ENGAGED IN ANY TRADE OR BUSINESS IN THE UNITED STATES OF AMERICA.

 5. I AM THE ____________________________________________________________________

(Executor, Administrator, Heir, Intestate Heir, Beneficiary, Husband, Wife, Son, or Daughter)
OF THE ESTATE OF _____________________________________________________________________.
(Decedent's Name)

6. THE DECEDENT HAD AN ACCOUNT(S) NUMBER(S) _______________, WITH

ISRAEL DISCOUNT BANK OF NEW YORK AND THE BALANCE AT THE DATE OF DEATH WAS

________________________. THIS ACCOUNT WAS NEVER USED IN CONNECTION WITH ANY

(Amount in US$)
TRADE OR BUSINESS IN THE UNITED STATES OF AMERICA.

7. I AM FAMILIAR WITH THE NATURE AND VALUE OF ALL UNITED STATES ASSETS

(INCLUDIBLE IN THE DECEDENT’S GROSS ESTATE FOR UNITED STATES ESTATE TAX

PURPOSES AS DESCRIBED IN SECTION 2103 AND 2104 OF THE UNITED STATES INTERNAL

REVENUE CODE OF 1986, AS AMENDED, AND REGULATIONS THEREUNDER). IN ADDITION TO

THE ACCOUNT OR ACCOUNTS WITH ISRAEL DISCOUNT BANK OF NEW YORK, THE DECEDENT

HELD THE FOLLOWING UNITED STATES ASSETS AT THE DATE OF DEATH:

________________________________________________

(list assets and values on attached sheet OR state "NONE")

8. DID DECEDENT LEAVE A WILL? YES NO

IF YES, PROVIDE COPY OF WILL.

9. ENCLOSED IS A COPY OF THE DEATH TAX RETURN OR INHERITANCE TAX

RETURN FILED WITH THE TAXING AUTHORITIES IN THE DECEDENT'S

JURISDICTION.

- OR -

NO DEATH TAX OR INHERITANCE TAX RETURN WAS FILED IN ANY

JURISDICTION OUTSIDE OF THE UNITED STATES.

 10. DID DECEDENT EVER FILE A UNITED STATES GIFT TAX RETURN OR OTHERWISE

MAKE GIFTS TREATED AS TAXABLE GIFTS FOR UNITED STATES GIFT TAX PURPOSES?

YES NO ____

11. THIS AFFIDAVIT IS MADE FOR THE PURPOSE OF INDUCING ISRAEL DISCOUNT

BANK OF NEW YORK TO MAKE PAYMENT AND DELIVERY OF THE BALANCE OF THE

AFORESAID ACCOUNT(S) PURSUANT TO THE INSTRUCTIONS OF THE UNDERSIGNED,

KNOWING THAT IN DOING SO ISRAEL DISCOUNT BANK OF NEW YORK RELIES UPON THE

CORRECTNESS OF THE STATEMENTS HEREIN CONTAINED AND THE UNDERSIGNED HEREBY

BINDS HIMSELF/HERSELF, HIS/HER HEIRS, EXECUTORS AND ADMINISTRATORS AND HIS/HER

SUCCESSORS TO INDEMNIFY AND HOLD ISRAEL DISCOUNT BANK OF NEW YORK FOREVER

HARMLESS FROM ALL LOSS, COST, DAMAGE OR EXPENSE, INCLUDING ATTORNEY FEE,

SUFFERED OR INCURRED BY IT BY REASON OF ITS HAVING MADE SUCH PAYMENT AND

DELIVERY AND ITS HAVING TAKEN ANY OTHER ACTION IN CONSIDERATION OF OR IN

RELIANCE UPON THE STATEMENTS HEREIN CONTAINED.

SIGNED UNDER PAINS AND PENALTIES OF PERJURY.

_________________________________________
Signature of Deponent

Date:____________________________________

4315800v.2