W. Va. Code R. agency 114, tit. 114, ser. 114-60, app C
Clearing Corporation Use
[This form affidavit is 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 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 _____________________________________, with a place of business at ________________________________________________________
_____________________________________________________________________________, (hereinafter called "the insurance company") pursuant to an agreement between the bank and the insurance company;
That it has caused certain securities to be credited to its bond entry account with the Federal Reserve Bank of ______________________________________________ under the Federal Reserve book-entry procedure; and that the schedule attached hereto is a true and complete statement of the securities of the insurance company of which the bank was custodian as of the close of business on ________________________________, which were in a "General" book-entry account maintained in the name of the bank on the books and records of the Federal Reserve Bank of _____________________________________________ at such date;
That the bank has the responsibility for the safekeeping of such securities both in the possession of the bank or in said "General" book-entry account as 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, said securities were the property of said 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 C