Form-22 Report Of Securities Page 2
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1
2
3AFFIDAVIT
being first duly sworn upon his/her oath, says that
he/she is
of the
and is familiar with the Statutes enacted by the General Assembly of the State of Indiana
and regulations for deposit.
He/She further says that the securities listed for deposit and/or that all instruments, papers
and documents evidencing and securing, or executed in connection with, and the title to the
real estate securing the mortgage loans listed are on the attached sheets. The Report of
Securities, sheet #
complies with all of the requirements of the Statutes of
Indiana and/or regulation for the Insurance Commissioner to the best of his/her knowledge
and belief, are eligible for deposit as such investments.
_________________________________
Officer of Company
Subscribed and sworn to before me this
day of
, 20
.
Notary Public
My Commission expires
_
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