State of Alabama Unified Judicial System Form C-10A Page 1 of 2 Case Number AFFIDAVIT OF SUBSTANTIAL HARDSHIP Rev.2/95 IN THE_______________________________________COURT OF ________________________________________, ALABAMA (Circuit, District, or Municipal) (Name of County or Municipality) STYLE OF CASE: _____________________________________________v. ___________________________________________ Plaintiff(s) Defendants(s) TYPE OF PROCEEDING:___________________________CHARGE(s) (if applicable):__________________________________ CIVIL CASE-- I, because of substantial hardship, am unable to pay the docket fee and service fees in this case. I request that payment of these fees be waived initially and taxed as costs at the conclusion of the case. CIVIL CASE-- (such as paternity, support, termination of parental rights, dependency) – I am financially unable to hire an attorney and I request that the court appoint one for me. CRIMINAL CASE-- I am financially unable to hire an attorney and request that the court appoint one for me. DELINQUENCY / NEED OF SUPERVISION-- I am financially unable to hire an attorney and request that the court appoint one for my child / me AFFIDAVIT SECTION 1. 1.```IDENTIFICATION Full name _____________________________________________________________________ Date of Birth _________________________ Spouse’s Full name (if married) ________________________________________________________________________________________ Complete Home address ______________________________________________________________________________________________ __________________________________________________________________________________________________________________ Number of people living in household ____________________________________________________________________________________ Home telephone number _________________________________________________ Occupation / Job ________________________________ Length of employment __________________________________________________ Driver’s license number __________________________________ *Social Security Number_________________________________________ Employer_____________________________________________ Employer’s telephone number_____________________________________ Employer’s address __________________________________________________________________________________________________ __________________________________________________________________________________________________________________ 2.````ASSISTANCE BENEFITS Do you or anyone residing in your household receive benefits from any of the following sources? (If so, please check those which apply) AFDC Food Stamps SSI Medicaid Other___________________________________________ 3. ``INCOME / EXPENSE STATEMENT Monthly Gross Income: Monthly Gross Income Spouse’s Monthly Gross Income (unless a marital offense) Other Earnings: Commissions, Bonuses, Interest Income, etc, Contributions from Other People Living in Household Unemployment / Workmen’s Compensation, Social Security, Retirements, etc, Other Income (be specific) _______________________ $________________ ________________ ________________ ________________ ________________ ________________ TOTAL MONTHLY GROSS INCOME Monthly Expenses: A. Living Expenses Rent / Mortgage Total Utilities: Gas, Electricity, Water, etc Food Clothing Health Care / Medical Insurance Car Payment(s) / Transportation Expenses Loan Payment(s) *OPTIONAL $____________________ $________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ American LegalNet, Inc. www.USCourtForms.com AFFIDAVIT OF SUBSTANTIAL HARDSHIP Form C-10A Page 2 of 2 Rev.2/95 Monthly Expenses:(cont’d page1) Credit Card Payment(s) Educational / Employment Expenses Other Expenses (be specific) _____________________ _____________________________________________ ________________ ________________ ________________ ________________ Sub-Total A $____________________ B. Child Support Payment(s) / Alimony $________________ C. Sub-Total Exceptional Expenses $________________ B $____________________ TOTAL MONTHLY EXPENSES (add subtotals from A & B monthly only) $____________________ Total Gross Monthly Income Less total monthly expenses: DISPOSABLE MONTHLY INCOME 4. 5. LIQUID ASSETS: Cash on Hand/Bank (or otherwise available such as stocks, bonds, certificates of deposit) Equity in Real Estate (value of property less what you owe) Equity in Personal Property, etc. (such as the value of motor vehicles, stereo, VCR, furnishing, jewelry, tools, guns, less what you owe) Other (be specific) Do you own anything else of value? Yes No (land, house, boat, TV, stereo, jewelry) If so, describe _____________________________________ _________________________________________________ TOTAL LIQUID ASSETS $____________________ $_________________ _________________ _________________ _________________ $____________________ Affidavit / Request I swear or affirm that the answers are true and reflect my current financial status. I understand that a false statement or answer to any question in the affidavit may subject me to the penalties of perjury, I authorize the court or its authorized representative to obtain records of information pertaining to my financial status from any source in order to verify information provided by me. I further understand and acknowledge that, if the court appoints an attorney to represent me, the court may require me to pay all or part of the fees and expenses of my court-appointed counsel. Sworn to and subscribed before me this ________________________________________________ Affiant’s Signature _________ day of ___________________, __________ _____________________________________________ Judge / Clerk / Notary _________________________________________________ Print or Type Name American LegalNet, Inc. www.USCourtForms.com