Alaska Administrative Code
Title 3 - Commerce, Community, and Economic Development
Part 2 - Division of Insurance
Chapter 21 - Insurer - Financial
Article 9 - Custodian of Insurer Assets
3 AAC 21.875 - Custodian affidavit when securities held by the custodian have not been redeposited elsewhere; Form A

A custodian required to produce an affidavit under 3 AAC 21.865(a) (11) when securities held by the custodian have not been redeposited elsewhere must use the following form, substituting the judicial district for the county if the affidavit is executed in this state:

FORM A

CUSTODIAN AFFIDAVIT

[For use by a custodian where securities entrusted to its care have not been redeposited elsewhere.]

STATE OF _____________________________________)) COUNTY OF _____________________________________) _____________________________________________________________________)

I, (name of officer), being duly sworn depose and say that I am (title of officer) of (name of custodian), a corporation organized under and pursuant to the laws of the (state) with the principal place of business at (address) (hereinafter "corporation"):

That my duties involve supervision of activities as custodian and records relating thereto;

That the corporation is custodian for certain securities of (insurer) having a place of business at (address) (hereinafter "insurer") pursuant to an agreement between the corporation and the insurer;

That the schedule attached hereto is a true and complete statement of securities that were in the custody of the corporation for the account of the insurer as of the close of business on (date); 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 insurer 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 out in the agreement between the corporation as custodian and the insurer; and

That, to the best of my knowledge and belief, unless otherwise shown on the schedule, the securities were the property of the insurer and were free of all liens, claims, or encumbrances whatsoever.

_________ Vice President or _________ [other authorized corporation officer]

Subscribed and sworn to before me this _________ day of ___________________, 20 _________.

_________

Notary Public in and for _________

Authority:AS 21.06.090

AS 21.21.410