N.D. Admin Code 45-03-23-03
General Authority: NDCC 28-32-02
Law Implemented: NDCC 26.1-05-35 APPENDIX I FORMA CUSTODIAN AFFIDAVIT (For use by a custodian where securities entrusted to its care have not been redeposited elsewhere) STATE OF ____________) ) ss. COUNTY OF ____________) ____________________, being duly sworn deposes and says that he or she is___________ of______________, a corporation organized under and pursuant to the laws of the__________with the principal place of business at __________________("corporation"): That his or her duties involve supervision of activities of the corporation as custodian and records relating to the corporation; That the corporation is custodian for certain securities of ______________________ having a place of business at __________________________ ("insurance company") pursuant to an agreement between the corporation and the insurance company; That the schedule attached is a true and complete statement of securities (other than those caused to be deposited with The Depository Trust Company or like entity or a Federal Reserve Bank under the TRADES or Treasury Direct systems) which were in the custody of the corporation for the account of the insurance company as of the close of business on_____________________; that, unless otherwise indicated on the schedule the next maturing and all subsequent coupons were then either attached to coupon bonds or in the process of collection; and that, unless otherwise shown on the schedule, all such securities were in bearer form or in registered form in the name of the insurance company or its nominee, or of the corporation or its nominee, or were in the process of being registered in such form; That the corporation as custodian has the responsibility for the safekeeping of the securities as that responsibility 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 of_______, 20___. __________________________(L.S.) Vice President (or other authorized officer) APPENDIX II 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 says that he or she is___________ of______________, a corporation organized under and pursuant to the laws of the__________with the principal place of business at __________________("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 __________________________ ("insurance company") pursuant to an agreement between the corporation and the insurance company; That the corporation has caused certain of the 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 custodian 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 of_______, 20___. __________________________(L.S.) Vice President (or other authorized officer) APPENDIX III 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 says that he or she is___________ of______________, a corporation organized under and pursuant to the laws of the__________with the principal place of business at __________________("corporation"): That his or her duties involve supervision of activities of the corporation as custodian and records relating to the corporation; That the corporation is custodian for certain securities of ______________________ ("insurance company") with a place of business at __________________________ 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 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____________________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 the 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 of_______, 20___. __________________________(L.S.) Vice President (or other authorized officer)