FORM C

CUSTODIAN AFFIDAVIT

(For use where ownership is evidenced by book entry at a Federal Reserve Bank)

STATE OF                            )

)    SS.:

COUNTY OF                           )

, being duly sworn deposes and says that he or she is                 of                                                     , a corporation organized under and pursuant to the laws of the                                  with the principal place of business at                                   (hereinafter called the "corporation"):

That his or her duties involve supervision of activities of the bank as custodian and records relating thereto;

That the corporation is custodian for certain securities of

having a place of business at

(hereinafter called the "insurance company") pursuant to an agreement between the corporation and the insurance company;

That it has caused certain securities to be credited to its book‑entry account with the Federal Reserve Bank of                                under the TRADES or Treasury Direct systems; and that the schedule attached hereto is a true and complete statement of the securities of the insurance company of which the corporation was custodian as of the close of business on       which were in a "General" book‑entry account maintained in the name of the corporation on the books and records of the Federal Reserve bank of                      at such date;

That any securities which are held as a statutory deposit and are not available for withdrawal without approval by the Commissioner of Insurance are noted by appropriate clear legend;

That the corporation has the responsibility for the safekeeping of such securities both in the possession of the corporation or in said "General" book‑entry account as is specifically set forth in the agreement between the corporation as custodian and the insurance company; and

That, to the best of his or her knowledge and belief, unless otherwise shown on the schedule, the securities were the property of the insurance company and were free of all liens, claims or encumbrances whatsoever.

Subscribed and sworn to before me this       day of                        , 20     .

Vice President [or other authorized officer]

Author: Commissioner of Insurance

Statutory Authority: Code of Ala. 1975, §§27-2-17, 27-37-1.

History: Revised (Forms A, B, and C): July 7, 2022; effective July 17, 2022. Published with LRS July 29, 2022. Rule is not subject to the Alabama Administrative Procedure Act.