Liberty Mutual · purchase affidavit packet · v1

Item #14 · pool cleaner

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.

⚠ Security · this document carries reproduced signatures
When exporting to PDF for transmission to Liberty, set a PDF password in the Save dialog (macOS Preview: Show Details → Security Options → Require password to open). Share the password with Liberty by a separate channel (phone call to your handler) — never embed the password in the same email as the PDF. Treat this artefact like a signed cheque.
Claim 046414618-01 / 046414618-02 · Item #14 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 2026-05-22 we purchased a Aiper Scuba S1 Robotic Pool Cleaner (2026 Upgrade, Renewed) for the sum of $549.99 USD from Amazon, as the like-kind functional replacement for item #14 on the claim inventory (originally claimed at $462.00).
  4. Original = Polaris Vac-Sweep 280 (pressure-side pool cleaner with mesh bag, requires booster pump), purchased June 2019 from Amazon for $462.33 (Order 112-3762439-2328239). Polaris Vac-Sweep 280 is now discontinued and replacement parts are scarce. Replacement: Aiper Scuba S1 Robotic Pool Cleaner (Renewed, $549.99 unit / $551.19 grand total after $30 coupon + tax). Liberty's bar is like-kind functional equivalent — both automatically clean the pool's floor and walls of debris that has sunk. Technology gap (pressure-side → cordless robotic) is acknowledged but does not break like-kind: same function, same surface treated, same outcome. Replacement is a manufacturer-refurbished unit sold by Aiper Direct Renewed (Amazon authorised) — explicitly chosen below new-condition pricing to stay close to Liberty's approved amount. Household absorbs the upgrade premium ($89.19 above $462 approved amount) out-of-pocket.
  5. A paid receipt evidencing this purchase is attached to this affidavit as Exhibit A (2026-05-22-aiper-scuba-s1-pool-cleaner-replacement-114-9817850-2986664-551usd.png).
  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 #14 Exhibit A · receipt · sheet 2 of 2
2026-05-22-aiper-scuba-s1-pool-cleaner-replacement-114-9817850-2986664-551usd.png Receipt file: 2026-05-22-aiper-scuba-s1-pool-cleaner-replacement-114-9817850-2986664-551usd.png — paperclip the printed receipt to this sheet OR embed the PDF before printing.