23 CAR pt. 13, Appendix B
(For use in instances where a custodian bank maintains securities on deposit with a clearing institution registered with the U.S. Securities and Exchange Commission.)
STATE OF ) ) SS.: COUNTY OF )
____, being duly sworn deposes and says that I am an officer of ___, a banking corporation organized under and pursuant to the laws of the. __, with its principal place of business at _____ (hereinafter called "bank");
That my duties involve supervision of activities of the bank as custodian and records relating thereto;
That the bank is custodian for certain securities of ____, with a place of business at ______ (hereinafter called "insurance company"), pursuant to an agreement between the bank and the insurance company;
I
That the bank has caused certain of such securities to be deposited with (name and address) ____ (hereinafter called "___"); and that the schedule attached hereto is a true and complete statement of the securities of the insurance company of which the bank was custodian as of the close of business on __, and which were so deposited with _____ at such date;
That the bank as custodian has the same responsibility for the safekeeping of such securities whether in the possession of the bank or deposited with ________ as that responsibility is specifically set forth in the agreement between the bank as custodian and the insurance company; and
That, to the best of my knowledge and belief, unless otherwise shown on the schedule, said securities were the property of said insurance company and were free of all liens, claims or encumbrances whatsoever.
Subscribed and sworn to before me this _ day of _, 19____
________ (L.S.)
TYPED NAME
NOTARY PUBLIC
TITLE