West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-60 - Affidavits Of Custodian Banks › Appendix B

Current through Register Vol. XLI, No. 28, July 12, 2024
Clearing Corporation Use
[This form affidavit is for use in instances where a
				  custodian bank 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 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
				  _____________________________________ ______________________________________, having
				  a place of business at _______________
				  ______________________________________________________________________________
_____________________________________________________________________________,
				  (hereinafter called "the insurance company") pursuant to an agreement between the
				  bank and the insurance company;
That the bank 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 bank was custodian as of the close of business on
				  _____________________________________________, and which were so deposited on such
				  date;
That the bank as custodian has the responsibility for the
				  safekeeping of the securities both in the possession of the bank or deposited with
				  _____________________________________________ 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, the securities were the property of the 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_____________________