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

Current through Register Vol. XLI, No. 28, July 12, 2024
Clearing Corporation Use
[This form affidavit is for use by a custodian bank where
				  securities entrusted to its care have not been redeposited elsewhere.]
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 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 Federal Reserve
				  book-entry procedure) which were in the custody of the bank 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 bank or its nominee, or were in the process of being registered in such
				  form;
That the bank as custodian has the responsibility for the
				  safekeeping of such securities as that responsibility 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_____________________