Louisiana Administrative Code
Title 37 - INSURANCE Part
Part XIII - Regulations
Chapter 105 - Regulation Number 83-Domestic Insurer's Use of Custodial Agreements and the Use of Clearing Corporations
Section XIII-10507 - Custodian Affidavit-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 says 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

of ______________, 20____

_______________________________ (L.S.)

Vice President [or other authorized officer]

AUTHORITY NOTE: Promulgated in accordance with Act 342 of the 2004 Louisiana Regular Legislative Session; R.S. 22:39(D).; and the Louisiana Administrative Procedure Act, R.S. 49:950 et seq.