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-10509 - Custodian Affidavit-Form B

CUSTODIAN AFFIDAVIT

(For use in instances where a custodian corporation 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 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 of the corporation 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 corporation 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 corporation was custodian as of the close of business on ____________________________________, and which were so deposited on such date;

That the corporation as custodian has the responsibility for the safekeeping of the securities both in the possession of the corporation or deposited with ________________________ as 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.