Neb. Admin. Code INSURANCE, DEPARTMENT OF, tit. 210, ch. 81, form A
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 states 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 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 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 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 such 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 ______________________(L.S.) of_____________, 20_____ Vice President or other authorized officer
Neb. Admin. Code INSURANCE, DEPARTMENT OF, tit. 210, ch. 81, form A