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DEKALB COUNTY SUPERIOR COURT
STATE OF GEORGIA
ROE ZARA 2
Plaintiff, Civil Action
VS.
Case Number
SHAYNA ELIZABETH LowRY ,
Defendant.
DOMESTIC RELATIONS FINANCIAL AFFIDAVIT
(1) Your Name: PROUT ZAkA Your Age: 32
Spouse’s Name: SHYNMA Elizaae TH Lowry Spouse’s Age: 32
Date of Marriage: 06/06 2013 Date of Separation: 9g Sloe! 2024
Names and year of birth of children for whom support is to be determined in this action:
Name Year of Birth Resides with
Names and year of birth of your other children:
Name Year of Birth Resides with
(2) SUMMARY OF YOUR INCOME AND NEEDS: (fill out this part after you complete pages 2-6)
(A) Gross Monthly Income (from Item 3A below) $000
(B) Net Monthly Income (from Item 3B below) * S000
(C) Average Monthly Expenses (Item 5A below) 4500
Monthly Payments to Creditors (Item 5B below) 500
Total Monthly Expenses & Payments to Creditors (Item 5C below) 5000
Domestic Relations Financial Affidavit - rev. January 8, 2007 - Tech, Rev. 09-2021 Page 1 of 6
Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society
— —
(3) (A) Your Gross MONTHLY INCOME: (Complete this section or attach Child Support Schedule A.
All income must be entered based on monthly average regardless of date of receipt.
Where applicable, income should be annualized.)
Salary or Wages — ATTACH COPIES OF 2 MOST RECENT WAGE STATEMENTS
Commissions, Fees & Tips
Income from self-employment, partnership, close corporations and independent contracts
(gross receipts minus ordinary and necessary expenses required to produce income)
ATTACH SHEET ITEMIZING YOUR CALCULATIONS $ 60.090
Rental income (gross receipts minus ordinary and necessary expenses required to produce income)
ATTACH SHEET ITEMIZING YOUR CALCULATIONS
Bonuses
Overtime Payments
Severance Pay
Recurring Income from Pensions or Retirement Plans
Interest and Dividends
Trust income
Income from Annuities
Capital Gains
Social Security Disability or Retirement Benefits
Worker’s Compensation Benefits
Unemployment Benefits
Judgments from Personal Injury or Other Chil Cases
Gifts (cash or other gifts that can be converted to cash)
Prizes & Lottery Winnings
Alimony and maintenance from persons not in this case
Assets which are used for support of family
Fringe Benefits (if significantly reduce living expenses)
Any Other Income (Do not include means-tested public assistance, such as TANF or food stamps.) -
TOTAL Gross Monthly Income (also write in 24 on page one) $ S990
(3)(@B) Net Monthly Income From Employment (deducting only state and federal taxes and $3 ¢0D0
FICA) (also write in 2B on page one)
Domestic Relations Financial Affidavit - rev. January 8, 2007 - Tech. Rev. 09-2021 Page2 of 6
Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society
Your Pay Period (i.e., monthly, weekly, etc.): Number of Exemptions Claimed
by You for Tax Purposes:
(4) ASSETS
(List all assets here, including both non-marital and marital property. If you claim or agree that all
or part of an asset is non-marital, indicate the non-marital portion under the appropriate spouse’s
column and state the amount and the basis: pre-marital, gift, inheritance, source of funds, etc. The
total value of each asset must be listed in the "value" column. "Value" means what you feel the item
of property would be worth if it were offered for sale.)
Separate Separate Basis of the Claim
Asset of Asset of (pre-marital, gift,
Description Value Plaintiff Defendant inheritance, etc.)
Cash . $ $ $
Stocks, Bonds $ $
CD’s / Money Market Accounts $ $
Bank Accounts (bank name and/or last four digits of the account number):
@ $ $
Q) $ $
@) $ $
Retirement Pensions, 401(k), IRA or
Profit-Sharing
$ $
Money Owed to You (or Spouse)
Tax Refund Owed to You
Real Estate (list properties & mortgages):
Home
Debt owed on Home $
Other Real Estate $
Debt owed on Other Real Estate $
Automobiles / Vehicles (list vehicles & amounts owed on each one):
() Leeg{ FORD F-200 $s (9009 $ 10000 $ 0 GET
Debt owed on Vehicle (1) $ 0
Q@) $
Debt owed on Vehicle (2) $
Domestic. Relations Financial Affidavit - rev. January 8, 2007 - Tech, Rev. 09-2021 Page 3 of 6
Provided by the DeKalb County Superior Court and the Atlanta Legal Aid SocietySociety
(4) ASSETS (continued) Separate Separate Basis of the Claim
Asset of Asset of (pre-marital, gift,
Description Value Plaintiff Defendant inheritance, etc.)
Life Insurance (net cash value) $
Furniture / Furnishings $
Jewelry $
Collectibles
Other Assets (specify):
$
TOTAL ASSETS $
CT
(5)(A) AVERAGE MONTHLY EXPENSES FOR YOU AND YOUR HOUSEHOLD
HOUSEHOLD EXPENSES
Mortgage or Rent Payments $l009 Gas
Property taxes $ Repairs & Maintenance $-
$-
Homeowner's / Renter’s Insurance $ Lawn Care
Electricity $ [sO Pest Control
Water Cable TV / Internet Access $ SO
Garbage & Sewer Misc. Household & Grocery Items $ S09
Telephones \sO Meals Outside Home $ S09
Residential Lines Other (specify)
Cellular Telephones I¢O
AUTOMOTIVE
Gasoline & Oil $ $90 Auto Tags / Registration / License $5
Repairs & Maintenance $ £00. Insurance $ 500
OTHER VEHICLES (boats, trailers, RVs, etc.)
Gasoline & Oil $ Tags / Registration / License
Repairs & Maintenance $ Insurance
Domestic Relations Financial Affidavit - rev. January 8, 2007 - Tech, Rev. 09-2021 Page4 of 6
Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society
CHILDREN’S EXPENSES
Child Care (total monthly cost) $ Allowance
School Tuition $ Children’s Clothing
Tutoring $ Diapers
Private lessons (e.g., music, dance) Medical, Dental, Prescriptions
(out-of-pocket uncovered expenses)
School Supplies / Expenses Grooming / Hygiene
Lunch Money Gifts from children to others
Other Educational Expenses (list type & amount): Entertainment
Activities (including extra-curricular,
$ school, religious, cultural, etc.)
$ Summer Camps
OTHER INSURANCE
Health Insurance $ Life Insurance
Children’s portion: $ Relationship of Beneficiary:
Dental Insurance $ Disability Insurance
Children’s portion: $ Other Insurance (specify)
Vision Insurance $
Children’s portion: $
YOUR OTHER EXPENSES
=_
Dry Cleaning & Laundry $ Publications
Clothing $ = Dues, Clubs
Medical / Dental / Prescription
- Religious & Charities —
(out-of-pocket uncovered expenses)
Your Gifts (special holidays) Pet expenses
Entertainment £00 Alimony Paid to Former Spouse
Recreational Expenses (e.g., fitness) Child Support Paid for other children
Vacations £00 Date of initial CS order:
Travel Expenses for Visitation $ Other (attach sheet to list)
TOTAL ABOVE MONTHLY EXPENSES (also write on first line of 2C on page one)
Domestic Relations Financial Affidavit - rev. January 8, 2007 - Tech. Rev. 09-2021 Page 5 of 6
Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society
(5)(@) Your PAYMENTS & DEBTS TO CREDITORS
Monthly (Please check one)
To Whom Balance Due
Payments Joint Plaintiff [Defendant]
[RS $ [$.009 $ 509 ¥
$ $
$ $
$ $
$ $
$ $
Total Monthly Payments to Creditors (also write this total on line 2 of 2C on page one) 599
(5)(C)TOTAL MONTHLY EXPENSES
$50.09
(Total Expenses from final line on page 5 + Total Monthly Payments to Creditors above)
(also write this total on line 3 of 2C-on page one)
—
ff Plaintiff O Defendant Prose
(Sign in front of notary public.)
Name:__ Rot T ZAkA
Address: 2341 SHALUOw 0g) BD ATLANTA
GA 203UI
Daytime Phone: _( Loy ) 468-6330 .
Subscribed and sworn before me on
Email: ARM T_ uy 16@ Hormay. coM
bo Mow ,202e/.
O74 d
“Pl blié “L
lov N) Od
sh Os. GWENDOLYN M HOOKS:
NOTARY PUBLIC
AT AS,te Gwinnett County
State of Georgia
My Comm. Expires November 3, 2026
MG
we daytt@r ew USCR24 approved corrected 2- Tech rev 2017-05; 2021-09.pa
% ~~
oF a
Domestic Relations Financial Affidavit - rev. January 8, 2007 - Tech. Rev. 09-2021 Page 6 of 6
Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society
,
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DEKALB COUNTY SUPERIOR COURT STATE OF GEORGIA ROE ZARA 2 Plaintiff, Civil Action VS. Case Number SHAYNA ELIZABETH LowRY , Defendant. DOMESTIC RELATIONS FINANCIAL AFFIDAVIT (1) Your Name: PROUT ZAkA Your Age: 32 Spouse’s Name: SHYNMA Elizaae TH Lowry Spouse’s Age: 32 Date of Marriage: 06/06 2013 Date of Separation: 9g Sloe! 2024 Names and year of birth of children for whom support is to be determined in this action: Name Year of Birth Resides with Names and year of birth of your other children: Name Year of Birth Resides with (2) SUMMARY OF YOUR INCOME AND NEEDS: (fill out this part after you complete pages 2-6) (A) Gross Monthly Income (from Item 3A below) $000 (B) Net Monthly Income (from Item 3B below) * S000 (C) Average Monthly Expenses (Item 5A below) 4500 Monthly Payments to Creditors (Item 5B below) 500 Total Monthly Expenses & Payments to Creditors (Item 5C below) 5000 Domestic Relations Financial Affidavit - rev. January 8, 2007 - Tech, Rev. 09-2021 Page 1 of 6 Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society — — (3) (A) Your Gross MONTHLY INCOME: (Complete this section or attach Child Support Schedule A. All income must be entered based on monthly average regardless of date of receipt. Where applicable, income should be annualized.) Salary or Wages — ATTACH COPIES OF 2 MOST RECENT WAGE STATEMENTS Commissions, Fees & Tips Income from self-employment, partnership, close corporations and independent contracts (gross receipts minus ordinary and necessary expenses required to produce income) ATTACH SHEET ITEMIZING YOUR CALCULATIONS $ 60.090 Rental income (gross receipts minus ordinary and necessary expenses required to produce income) ATTACH SHEET ITEMIZING YOUR CALCULATIONS Bonuses Overtime Payments Severance Pay Recurring Income from Pensions or Retirement Plans Interest and Dividends Trust income Income from Annuities Capital Gains Social Security Disability or Retirement Benefits Worker’s Compensation Benefits Unemployment Benefits Judgments from Personal Injury or Other Chil Cases Gifts (cash or other gifts that can be converted to cash) Prizes & Lottery Winnings Alimony and maintenance from persons not in this case Assets which are used for support of family Fringe Benefits (if significantly reduce living expenses) Any Other Income (Do not include means-tested public assistance, such as TANF or food stamps.) - TOTAL Gross Monthly Income (also write in 24 on page one) $ S990 (3)(@B) Net Monthly Income From Employment (deducting only state and federal taxes and $3 ¢0D0 FICA) (also write in 2B on page one) Domestic Relations Financial Affidavit - rev. January 8, 2007 - Tech. Rev. 09-2021 Page2 of 6 Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society Your Pay Period (i.e., monthly, weekly, etc.): Number of Exemptions Claimed by You for Tax Purposes: (4) ASSETS (List all assets here, including both non-marital and marital property. If you claim or agree that all or part of an asset is non-marital, indicate the non-marital portion under the appropriate spouse’s column and state the amount and the basis: pre-marital, gift, inheritance, source of funds, etc. The total value of each asset must be listed in the "value" column. "Value" means what you feel the item of property would be worth if it were offered for sale.) Separate Separate Basis of the Claim Asset of Asset of (pre-marital, gift, Description Value Plaintiff Defendant inheritance, etc.) Cash . $ $ $ Stocks, Bonds $ $ CD’s / Money Market Accounts $ $ Bank Accounts (bank name and/or last four digits of the account number): @ $ $ Q) $ $ @) $ $ Retirement Pensions, 401(k), IRA or Profit-Sharing $ $ Money Owed to You (or Spouse) Tax Refund Owed to You Real Estate (list properties & mortgages): Home Debt owed on Home $ Other Real Estate $ Debt owed on Other Real Estate $ Automobiles / Vehicles (list vehicles & amounts owed on each one): () Leeg{ FORD F-200 $s (9009 $ 10000 $ 0 GET Debt owed on Vehicle (1) $ 0 Q@) $ Debt owed on Vehicle (2) $ Domestic. Relations Financial Affidavit - rev. January 8, 2007 - Tech, Rev. 09-2021 Page 3 of 6 Provided by the DeKalb County Superior Court and the Atlanta Legal Aid SocietySociety (4) ASSETS (continued) Separate Separate Basis of the Claim Asset of Asset of (pre-marital, gift, Description Value Plaintiff Defendant inheritance, etc.) Life Insurance (net cash value) $ Furniture / Furnishings $ Jewelry $ Collectibles Other Assets (specify): $ TOTAL ASSETS $ CT (5)(A) AVERAGE MONTHLY EXPENSES FOR YOU AND YOUR HOUSEHOLD HOUSEHOLD EXPENSES Mortgage or Rent Payments $l009 Gas Property taxes $ Repairs & Maintenance $- $- Homeowner's / Renter’s Insurance $ Lawn Care Electricity $ [sO Pest Control Water Cable TV / Internet Access $ SO Garbage & Sewer Misc. Household & Grocery Items $ S09 Telephones \sO Meals Outside Home $ S09 Residential Lines Other (specify) Cellular Telephones I¢O AUTOMOTIVE Gasoline & Oil $ $90 Auto Tags / Registration / License $5 Repairs & Maintenance $ £00. Insurance $ 500 OTHER VEHICLES (boats, trailers, RVs, etc.) Gasoline & Oil $ Tags / Registration / License Repairs & Maintenance $ Insurance Domestic Relations Financial Affidavit - rev. January 8, 2007 - Tech, Rev. 09-2021 Page4 of 6 Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society CHILDREN’S EXPENSES Child Care (total monthly cost) $ Allowance School Tuition $ Children’s Clothing Tutoring $ Diapers Private lessons (e.g., music, dance) Medical, Dental, Prescriptions (out-of-pocket uncovered expenses) School Supplies / Expenses Grooming / Hygiene Lunch Money Gifts from children to others Other Educational Expenses (list type & amount): Entertainment Activities (including extra-curricular, $ school, religious, cultural, etc.) $ Summer Camps OTHER INSURANCE Health Insurance $ Life Insurance Children’s portion: $ Relationship of Beneficiary: Dental Insurance $ Disability Insurance Children’s portion: $ Other Insurance (specify) Vision Insurance $ Children’s portion: $ YOUR OTHER EXPENSES =_ Dry Cleaning & Laundry $ Publications Clothing $ = Dues, Clubs Medical / Dental / Prescription - Religious & Charities — (out-of-pocket uncovered expenses) Your Gifts (special holidays) Pet expenses Entertainment £00 Alimony Paid to Former Spouse Recreational Expenses (e.g., fitness) Child Support Paid for other children Vacations £00 Date of initial CS order: Travel Expenses for Visitation $ Other (attach sheet to list) TOTAL ABOVE MONTHLY EXPENSES (also write on first line of 2C on page one) Domestic Relations Financial Affidavit - rev. January 8, 2007 - Tech. Rev. 09-2021 Page 5 of 6 Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society (5)(@) Your PAYMENTS & DEBTS TO CREDITORS Monthly (Please check one) To Whom Balance Due Payments Joint Plaintiff [Defendant] [RS $ [$.009 $ 509 ¥ $ $ $ $ $ $ $ $ $ $ Total Monthly Payments to Creditors (also write this total on line 2 of 2C on page one) 599 (5)(C)TOTAL MONTHLY EXPENSES $50.09 (Total Expenses from final line on page 5 + Total Monthly Payments to Creditors above) (also write this total on line 3 of 2C-on page one) — ff Plaintiff O Defendant Prose (Sign in front of notary public.) Name:__ Rot T ZAkA Address: 2341 SHALUOw 0g) BD ATLANTA GA 203UI Daytime Phone: _( Loy ) 468-6330 . Subscribed and sworn before me on Email: ARM T_ uy 16@ Hormay. coM bo Mow ,202e/. O74 d “Pl blié “L lov N) Od sh Os. GWENDOLYN M HOOKS: NOTARY PUBLIC AT AS,te Gwinnett County State of Georgia My Comm. Expires November 3, 2026 MG we daytt@r ew USCR24 approved corrected 2- Tech rev 2017-05; 2021-09.pa % ~~ oF a Domestic Relations Financial Affidavit - rev. January 8, 2007 - Tech. Rev. 09-2021 Page 6 of 6 Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society ,