23 CAR pt. 13, Appendix C
(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 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 it has caused certain of such securities to be credited to its book-entry account with the Federal Reserve Bank of ____ under the Federal Reserve book-entry procedure; 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 ___, which were in a book-entry account maintained in the name of the bank on which the books and records of the Federal Reserve Bank of _____ as such date;
That the bank has the same responsibility for the safekeeping of such securities whether in the possession of the bank or in said book-entry account 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