3 Alaska Admin. Code § 21.885
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 has caused certain securities to be credited to its book entry account with the Federal Reserve Bank of _____________________________________ under the TRADES or Treasury Direct system; and that the schedule attached hereto is a true and complete statement of the securities of the insurer of which the corporation was custodian as of the close of business on (date), 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 that date;
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 _________
3 AAC 21.885
Authority:AS 21.06.090
AS 21.21.410