Liberty Mutual · purchase affidavit packet · v1

Item #15 · saw horse

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 #15 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. Pre-loss inventory evidence — item destroyed in the covered event: 1× Logosol Smart-Holder Saw Horse, Folding Wood Holder, originally purchased from Amazon.com on 2020-05-15 for a total of $135.68 USD (order #114-9466821-2949066), delivered to the insured property on 2020-05-20, 435 days before the loss event of 2021-07-29.
  4. Replacement of the destroyed item has not yet been completed. We will purchase a like-kind functional replacement and amend this affidavit accordingly, attaching the paid receipt as Exhibit A.
  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 #15 Exhibit A · receipt · sheet 2 of 2
Attach paid receipt here Receipt PDF/image will be embedded here once captured via dropzone and synced.