A custodian required to produce an affidavit under 3 AAC 21.865(a)(11) when securities are evidenced by book-entry at a Federal Reserve Bank must use the following form, substituting the judicial district for the county if the affidavit is executed in this state: FORM C CUSTODIAN AFFIDAVIT [For use by a custodian where security ownership is evidenced by book entry at a Federal Reserve Bank.] STATE OF _______________ ))COUNTY OF _______________ ) _______________ ) I, (name of officer), being duly sworn depose and say that I am (title of officer) of (name of custodian), a corporation organized under and pursuant to the laws of the (state) with the principal place of business at (address) (hereinafter "corporation"): That my duties involve supervision of activities as custodian and records relating thereto; That the corporation is custodian for certain securities of (insurer) having a place of business at (address) (hereinafter "insurer") pursuant to an agreement between the corporation and the insurer; ________________________ That the corporation as custodian has the responsibility for the safekeeping of the securities both in the possession of the corporation or in the ''general'' book entry account as is specifically set out in the agreement between the corporation as custodian and the insurer; and That, to the best of my knowledge and belief, unless otherwise shown on the schedule, the securities were the property of the insurer and were free of all liens, claims, or encumbrances whatsoever. _________ Vice President or _________ [other authorized corporation officer] Subscribed and sworn to before me this _________ day of ___________________ , 20 _________ . _________ Notary Public in and for _________

(Eff. 8/31/2008, Register 187)

Authority: AS 21.06.090, AS 21.21.410