23 CAR pt. 13, Appendix D
(For use in instances where securities are deposited directly with a clearing corporation 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 ________ as custodian and records relating thereto;
That ____ is custodian for certain securities of ___, with a place of business at __ (hereinafter called "insurance company"), pursuant to an agreement between _____ and the insurance company; I
That the schedule attached hereto is a true and complete statement of securities which were in the custody of ____ for the account of the insurance company as of the close of business on ______;
That ____ as custodian has the responsibility for the safekeeping of such securities (whether in the possession of ___, deposited with a Federal Reserve Bank or deposited with another person acting as custodian for __) as that responsibility is specifically set forth in the agreement between _____ 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 _, 200__
TYPED NAME
NOTARY PUBLIC
TITLE