Neb. Admin. Code INSURANCE, DEPARTMENT OF, tit. 210, ch. 81, form C
CUSTODIAN AFFIDAVIT
[For use where ownership is evidenced by book entry at a Federal Reserve Bank.]
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 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 it has caused certain securities to be credited to its book-entry account with the Federal Reserve Bank of____________________under the TRADES or Treasury Direct systems; and that the schedule attached hereto is a true and complete statement of securities of the insurance company of which the corporation was custodian as of the close of business on______________, 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 such date;
That the corporation has the responsibility for the safekeeping of such securities both in the possession of the corporation or in the "general" book-entry account 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 C