W. Va. Code R. agency 114, tit. 114, ser. 114-60, app A
Clearing Corporation Use
[This form affidavit is for use by a custodian bank 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 banking corporation organized under and pursuant to the laws of the _____________________ with the principal place of business at _______________________________________________ ______________________________________________________________________________
_____________________________________________________________________________. (hereinafter called "the bank"):
That his or her duties involve supervision of activities of the bank as custodian and records relating thereto; That the bank is custodian for certain securities of _______________________ __________________________________, having a place of business at____________________ ______________________________________________________________________________
_____________________________________________________________________________, (hereinafter called "the insurance company") pursuant to an agreement between the bank and the insurance company;
That the schedule attached hereto 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 Federal Reserve book-entry procedure) which were in the custody of the bank 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 bank or its nominee, or were in the process of being registered in such form;
That the bank as custodian has the responsibility for the safekeeping of such securities as that responsibility is specifically set forth in the agreement between the bank 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.
The foregoing instrument was acknowledged before me this ______ day of __________________, 20____, by ____________________________________________________________________ (Name of officer or agent, title of officer or agent)
of ________________________________________________________, (Name of corporation acknowledging)
a _____________________________ corporation, on behalf of the corporation. (state or place of incorporation)
Notary:___________________________________
My commission expires_____________________
W. Va. Code R. agency 114, tit. 114, ser. 114-60, app A