Neb. Admin. Code INSURANCE, DEPARTMENT OF, tit. 210, ch. 81, form B
CUSTODIAN AFFIDAVIT
[For use in instances where a custodian corporation maintains securities on deposit with The Depository Trust Company or like entity.]
STATE OF___________________)
) ss.
COUNTY OF____________________)
__________________________________, being duly sworn deposes and states 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 as of the corporation 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 the corporation has caused certain of such securities to be deposited with __________________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____________________, and which were so deposited on such date;
That the corporation as custodian has the responsibility for the safekeeping of the securities both in the possession of the corporation or deposited with ___________________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 __________________________(L.S.) of_______________, 20_____ Vice President or other authorized officer
Neb. Admin. Code INSURANCE, DEPARTMENT OF, tit. 210, ch. 81, form B