(For use by a custodian bank where securities entrusted to its care have not been redeposited elsewhere.)

__________, being duly sworn deposes and says that I am an officer of __________,, a banking corporation organized under and pursuant to the laws of the. __________, with its principal place of business at __________ (hereinafter called “bank”);

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

That the bank is custodian for certain securities of __________, with a place of business at __________ (hereinafter called “insurance company”), pursuant to an agreement between the bank and the insurance company; I

That the schedule attached hereto is a true and complete statement of securities (other than those caused to be deposited with a clearing institution registered with the U.S. Securities and Exchange Commission 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 a nominee of the bank, 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 my knowledge and belief, unless otherwise shown on the schedule, said securities were the property of said insurance company and were free of all liens, claims or encumbrances whatsoever.