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DEKALB COUNTY SUPERIOR COURT
STATE OF GEORGIA
Achit Vag. Plaintiff, Civil Action
Yuya. Lenn Defend. ]
Case Number
DOMESTIC RELATIONS FINANCIAL AFFIDAVIT
(1) Your Name: CHAU nge Your Age: BY
Spouse’s Name: ACA 4 coe Spouse’s Age: OL
Date of Marriage: (0) lg} 19 Date of Separation: 4 | W | VE
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 34 below) § 0.06
(B) Net Monthly Income (from Item 3B below) $
(C) Average Monthly Expenses (Item 5A below) $ | G00
Monthly Payments to Creditors (Item 5B below)
—
Total Monthly Expenses & Payments to Creditors (Item 5C below)
— =
$ |, 900
Domestic Relations Financial Affidavit - rev. January 8, 2007 - Tech, Rev. 09-2021
Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society
Page | of 6
Z
_ -
_ —_ —
(3) (A) Your Gross Monray IN (COME: (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 $ 0.00.
Commissions, Fees & Tips
$
Income from self-employment, partnership, close corporations and indepen
dent contracts
(gross receipts minus ordinary and necessa ry expenses required to produce
income) $
#0
ATTACH SHEET ITEMIZING YOUR CALCULATIONS
Rental income (gross receipts minus ordinary and necessa ry expenses required to produce income)
ATTA
SHEET CH
ITEMIZING YOUR CALCULATK IONS
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 Civil Cases
Gifts (cash or other gifts that can be converted to cash)
Prizes & Lottery Winnings :
Alimony and maintenance from persons rot 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)
= — =
(3)(B) Net Monthly Income From Employment (deducting only state and federal
taxes and
FICA) (also write in 2B on page one)
Domestic Relations Financial Affidavit - rev. January 8, 2007 - Tech. Rev, 09-2021
Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society Page 2 of 6
Your Pay Period (i.¢., monthly, weekly, etc.): Number of Exemptions Claimed
by You for Tax Purposes:
a
(4) AssETS
(List ail 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):
cy NOS FAIGO- s 40.00. $ fre-narital|-
Q) $ $
GB) $
Retirement Pensions, 401(k), IRA or
Profit-Sharing
Money Owed to You (or Spouse) 31,000.
Tax Refund Owed to You
Real Estate (list-properties & mortgages):
Home
Debt owed on Home $
Other Real Estate $
Ae
Debt owed on Other Real Estate | $ é
Automobiles / Vehicles (list vehicles & amounts owed on each one):
(1) $ $
&
-Debt owed on Vehicle (1) $ “ft
(2) $
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 inheritance, etc.)
Defendant
Life Insuraice (net cash value) $
Fumiture / Furnishings $
Jewelry $
Collectibles $
Other Assets (specify): 1,000. $2000, |OurceoF Funds.
102
Cherolcue,
TOTAL ASSETS $)-,000
———— = ——————
(5A) ” AVERAGE MONTHLY EXPENSES FOR YOU AND YOUR HOUSEHOLD
HOUSEHOLD EXPENSES
Mortgage or Rent Payments
400 Gas Ls |O0—
Property taxes Repairs & Maintenance
Homeowner’s / Renter’s Insurance Lawn Care
Electricity Pest Control
Water Cable TV / Internet Access
Garbage & Sewer Misc. Household & Grocery Items
s 300
Telephones Meals Outside Home $ 100
Residential Lines
Other (avec) AA
CAT G $168
Cellular Telephones
AUTOMOTIVE
Gasoline & Oil
$100 Auto Tags / Registration / License
Repairs & Maintenance $ Insurance s 00.
OTHER VEHICLES (boats, trailers, RVs, etc.)
Gasoline & Oil $ Tags / Registration / License
Repairs & Maintenance $ Insurance
Domestic Relations Financial Affidavit - rev. January8, 2007 - Tech. Rev. 09-2021
Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society
Page 4 of 6
2 ~
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 $3 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
(out-of-pocket uncovered expenses) Religious & Charities
Your Gifts (special holidays) Pet expenses
Entertainment Alimony Paid to Former Spouse
Recreational Expenses (e.y,, fitness) Child Support Paid for other children
Vacations $ Date of initial CS order:
Travel Expenses for Visitation 3 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
Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society
Page 5 of 6
(5)(B) Your PAYMENTS & DEBTS TO CREDITORS
Monthly (Please check one)
, ~ oT Whom Balance Due
Payments Joint Plaintiff |Defendant|
== = = = > =
ft oot | $e + ‘
-
LS. 5150 00.4|8G00.
$ $
$ $
$ $
$ $
Total Monthly Payments to Creditors (also write this sal on line 2 of 2C on page one) 3
(3)(C)TOTAL MONTHLY EXPENSES
(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)
5,500.
fo?)
-
i
OPAintif® 71 lendant Proke7
Int of notary public.)
Name: “ante Owl.
Address: uo
Daytime Phone: C )
Subscribed and sworn before me on
Email: Adyewolr aknhh(®)qiiai:-Com.
CUA 20 XY,
OY
UY
t_/V) NOW
Noi ary Publ
5
22 te, GWENDOLYN M HOOKS
on Os NOTARY PUBLIC
wr Y TOS
Tee Gwinnett County
State of Georgia
My Comm. Expires November 3, 2026
pro DRS Affidatit
for’ n -09.wpd
Tm
‘Lann. ae= R24 approved corrected 2 - Tech rev 2017-05; 2021
«S =
. ow
Domestic Relations Fir ral Affidavit - rey, January 8, 2007 - Tech, Rev. 09-2021
Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society Page 6 of 6
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DEKALB COUNTY SUPERIOR COURT STATE OF GEORGIA Achit Vag. Plaintiff, Civil Action Yuya. Lenn Defend. ] Case Number DOMESTIC RELATIONS FINANCIAL AFFIDAVIT (1) Your Name: CHAU nge Your Age: BY Spouse’s Name: ACA 4 coe Spouse’s Age: OL Date of Marriage: (0) lg} 19 Date of Separation: 4 | W | VE 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 34 below) § 0.06 (B) Net Monthly Income (from Item 3B below) $ (C) Average Monthly Expenses (Item 5A below) $ | G00 Monthly Payments to Creditors (Item 5B below) — Total Monthly Expenses & Payments to Creditors (Item 5C below) — = $ |, 900 Domestic Relations Financial Affidavit - rev. January 8, 2007 - Tech, Rev. 09-2021 Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society Page | of 6 Z _ - _ —_ — (3) (A) Your Gross Monray IN (COME: (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 $ 0.00. Commissions, Fees & Tips $ Income from self-employment, partnership, close corporations and indepen dent contracts (gross receipts minus ordinary and necessa ry expenses required to produce income) $ #0 ATTACH SHEET ITEMIZING YOUR CALCULATIONS Rental income (gross receipts minus ordinary and necessa ry expenses required to produce income) ATTA SHEET CH ITEMIZING YOUR CALCULATK IONS 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 Civil Cases Gifts (cash or other gifts that can be converted to cash) Prizes & Lottery Winnings : Alimony and maintenance from persons rot 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) = — = (3)(B) Net Monthly Income From Employment (deducting only state and federal taxes and FICA) (also write in 2B on page one) Domestic Relations Financial Affidavit - rev. January 8, 2007 - Tech. Rev, 09-2021 Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society Page 2 of 6 Your Pay Period (i.¢., monthly, weekly, etc.): Number of Exemptions Claimed by You for Tax Purposes: a (4) AssETS (List ail 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): cy NOS FAIGO- s 40.00. $ fre-narital|- Q) $ $ GB) $ Retirement Pensions, 401(k), IRA or Profit-Sharing Money Owed to You (or Spouse) 31,000. Tax Refund Owed to You Real Estate (list-properties & mortgages): Home Debt owed on Home $ Other Real Estate $ Ae Debt owed on Other Real Estate | $ é Automobiles / Vehicles (list vehicles & amounts owed on each one): (1) $ $ & -Debt owed on Vehicle (1) $ “ft (2) $ 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 inheritance, etc.) Defendant Life Insuraice (net cash value) $ Fumiture / Furnishings $ Jewelry $ Collectibles $ Other Assets (specify): 1,000. $2000, |OurceoF Funds. 102 Cherolcue, TOTAL ASSETS $)-,000 ———— = —————— (5A) ” AVERAGE MONTHLY EXPENSES FOR YOU AND YOUR HOUSEHOLD HOUSEHOLD EXPENSES Mortgage or Rent Payments 400 Gas Ls |O0— Property taxes Repairs & Maintenance Homeowner’s / Renter’s Insurance Lawn Care Electricity Pest Control Water Cable TV / Internet Access Garbage & Sewer Misc. Household & Grocery Items s 300 Telephones Meals Outside Home $ 100 Residential Lines Other (avec) AA CAT G $168 Cellular Telephones AUTOMOTIVE Gasoline & Oil $100 Auto Tags / Registration / License Repairs & Maintenance $ Insurance s 00. OTHER VEHICLES (boats, trailers, RVs, etc.) Gasoline & Oil $ Tags / Registration / License Repairs & Maintenance $ Insurance Domestic Relations Financial Affidavit - rev. January8, 2007 - Tech. Rev. 09-2021 Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society Page 4 of 6 2 ~ 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 $3 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 (out-of-pocket uncovered expenses) Religious & Charities Your Gifts (special holidays) Pet expenses Entertainment Alimony Paid to Former Spouse Recreational Expenses (e.y,, fitness) Child Support Paid for other children Vacations $ Date of initial CS order: Travel Expenses for Visitation 3 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 Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society Page 5 of 6 (5)(B) Your PAYMENTS & DEBTS TO CREDITORS Monthly (Please check one) , ~ oT Whom Balance Due Payments Joint Plaintiff |Defendant| == = = = > = ft oot | $e + ‘ - LS. 5150 00.4|8G00. $ $ $ $ $ $ $ $ Total Monthly Payments to Creditors (also write this sal on line 2 of 2C on page one) 3 (3)(C)TOTAL MONTHLY EXPENSES (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) 5,500. fo?) - i OPAintif® 71 lendant Proke7 Int of notary public.) Name: “ante Owl. Address: uo Daytime Phone: C ) Subscribed and sworn before me on Email: Adyewolr aknhh(®)qiiai:-Com. CUA 20 XY, OY UY t_/V) NOW Noi ary Publ 5 22 te, GWENDOLYN M HOOKS on Os NOTARY PUBLIC wr Y TOS Tee Gwinnett County State of Georgia My Comm. Expires November 3, 2026 pro DRS Affidatit for’ n -09.wpd Tm ‘Lann. ae= R24 approved corrected 2 - Tech rev 2017-05; 2021 «S = . ow Domestic Relations Fir ral Affidavit - rey, January 8, 2007 - Tech, Rev. 09-2021 Provided by the DeKalb County Superior Court and the Atlanta Legal Aid Society Page 6 of 6