23 CAR pt. 13, Appendix D. Exhibit D - Custodian Affidavit

EXHIBIT D CUSTODIAN AFFIDAVIT (For use in instances where securities are deposited directly with a clearing corporation registered with the U.S. Securities and Exchange Commission.) STATE OF ) ) SS.: COUNTY OF ) _________________________, being duly sworn deposes and says that I am an officer of _________________________, , a banking corporation organized under and pursuant to the laws of the. _________________________, with its principal place of business at ____________________ (hereinafter called "bank"); That my duties involve supervision of activities of ____________________ as custodian and records relating thereto; That ____________________ is custodian for certain securities of _________________________, with a place of business at _________________________ (hereinafter called "insurance company"), pursuant to an agreement between ____________________ and the insurance company; I That the schedule attached hereto is a true and complete statement of securities which were in the custody of ____________________ for the account of the insurance company as of the close of business on _________________________; That ____________________ as custodian has the responsibility for the safekeeping of such securities (whether in the possession of ____________________, deposited with a Federal Reserve Bank or deposited with another person acting as custodian for ____________________) as that responsibility is specifically set forth in the agreement between ____________________ as custodian and the insurance company; and That, to the best of my 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. Subscribed and sworn to before me this _____ day of __________, 200 ________________________ TYPED NAME ______________________________ ______________________________ NOTARY PUBLIC TITLE