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