Liberty Mutual · purchase affidavit packet · v1

Item #05 · blower

Print + sign (both insureds) + attach paid receipt + mail to claims address. 28 USC §1746 self-sworn declaration — no notary required for federal courts; Liberty accepts in lieu of notarisation for replacement-cost releases.

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Claim 046414618-01 / 046414618-02 · Item #05 Affidavit · sheet 1 of 2

AFFIDAVIT OF PURCHASE

Replacement-cost coverage · personal property contents
Commonwealth of Pennsylvania
County of Bucks

We, DAN SELLARS and AUDREY LAM, being the named insureds under the policy referenced below, declare under penalty of perjury under the laws of the United States of America that the following is true and correct:

  1. We are the named insureds on Liberty Mutual Personal Insurance Company homeowners policy H3V-281-240408-75, claim number 046414618-01 / 046414618-02, on the insured property at 6279 GREENHILL RD, NEW HOPE, PA 18938-9646.
  2. The covered loss occurred on 2021-07-29 and is described in Liberty's records as: Storm/tree damage — tree fall with associated structural and electrical damage.
  3. On ________________ we engaged ________________ (pending — at the shop now) to repair the damaged item described above (item #05 on the claim inventory, originally claimed at $225.00) item for the sum of $____________ USD, restoring it to working condition. A paid repair invoice is attached as Exhibit A. Repair was elected in lieu of full replacement as the lower-cost path to functional restoration; per Liberty's settlement-email language of 2026-01-13 ("if you spend less than estimated for the items replacement, we will release the recoverable depreciation payment up to the amount you spent"), the recoverable depreciation for this line is hereby requested up to the actual repair cost.
  4. REPAIR mode (Husqvarna 150BT at the shop). Like-kind argument N/A — repair restores the existing unit to working condition.
  5. A paid receipt evidencing this purchase is attached to this affidavit as Exhibit A ([receipt filename — attach when finalised]).
  6. We make this declaration knowing that it will be relied upon by Liberty Mutual Personal Insurance Company in evaluating our claim and releasing the recoverable depreciation withhold associated with this line item.
Dan Sellars · named insured · 2026-05-22
Audrey Lam · named insured · 2026-05-22

Pursuant to 28 U.S.C. § 1746, we declare under penalty of perjury that the foregoing is true and correct. Executed at New Hope, Pennsylvania on the date(s) signed above.

Claim 046414618-01 / 046414618-02 · Item #05 Exhibit A · receipt · sheet 2 of 2
Attach paid receipt here Receipt PDF/image will be embedded here once captured via dropzone and synced.