Liberty Mutual · purchase affidavit packet · v1

Item #18 · toilet

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 #18 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. 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.
  4. Original = Porcher 1 Champion One-Piece Elongated Toilet (model 97420), a premium designer European-style fixture purchased March 2006 from homeclick.com for $519.35. Destroyed in 2021-07-29 shed collapse. Porcher's American Standard line is now discontinued under the same model number, so exact like-for-like replacement is not market-available. Replacement: EPLO iX7-PRO Smart Toilet (ASIN B0D83KVTBW) — same like-kind function (elongated one-piece toilet) with modern feature additions (heated seat, bidet, auto open/close, instant warm water, integrated dryer). Liberty's approved $519.00 covers the like-kind replacement amount; the household absorbs the upgrade premium above $519 out-of-pocket. Variance is documented and within Liberty's like-kind functional equivalence standard per the variance-defence framework.
  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 #18 Exhibit A · receipt · sheet 2 of 2
Attach paid receipt here Receipt PDF/image will be embedded here once captured via dropzone and synced.