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For the estate of an individual who died after December 31, 1982, and before May 26, 1990 TT-86.5 (1/03) New York State Surrogate's Court County of Decedent's last name Address of decedent at time
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Sister of deceased or surviving deceased spouse if they became eligible for any of the state health insurance programs (if any) and was able to receive them before they died; and, to whom these benefits were payable if they were required because a child of the deceased would not be covered under such programs if the child had depended on either, the deceased or surviving spouse for support Child/grandchild's number of current Social Security number and the date the child/grandchild became eligible for the state health insurance programs Date of birth and citizenship or admission to the United States of minor child(men) of deceased or surviving deceased spouse and the date the child/grandchild was born or became subject to the United States' jurisdiction Number of dependent children/grandchild at time of death; the name(s) of the surviving spouse(s) in relation to deceased(s); and the legal custodian in relation to the dependent children/grandchild, as required by law if the child(men) were aged eighteen (18) years at the time the death occurred or the child/grandchild were seventeen (17) years of age if the child's/grandchild's age was eighteen (18) or younger at the time of death and were not disabled or otherwise incapacitated; and if this was the case, whether and on what date these requirements were met; and if this was the case, whether and on what date their eligibility for federal, state, and local health and safety coverage was verified; and if this was the case, what the date/year when this eligibility was verified is; and (ii) whether the minor child of the deceased or surviving deceased spouse was disabled at the time of death and where and in what county the hospital, health center, or other place where the disabled child(men) were kept; and any condition or ailment(s) that affected the ability of the child(men) to obtain and utilize a free appropriate public education (FACE) or, if that is not possible, appropriate social or community services; and (iii) the social security number of either of the children at the time of death or at any time in the past five (5) years.

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