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 __________________________ (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 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
of ______________ , 20____ _______________________________ (L.S.)
Vice President [or other authorized officer]