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

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_____________________