State of Alabama Unified Judicial System Form C-10 Page 1 of 2 Rev. 7/2019 AFFIDAVIT OF SUBSTANTIAL HARDSHIP (Section 12-19-70, Ala. Code 1975) Court Case Number IN THE COURT OF COUNTY, ALABAMA (Circuit or District) (Name of County) STYLE OF CASE: v. (Plaintiff(s)) (Defendant(s)) TYPE OF PROCEEDING: CIVIL (CV, DV, DR, SM) CASE -- I, because of financial hardship, am unable to pay the docket fee in this case. I request that payment of this fee be waived initially and taxed as a cost at the conclusion of the case. AFFIDAVIT SECTION 1. IDENTIFICATIONFull Name Date of Birth Spouse222s Full Name (if married) Complete Home Address Number of People Living in Household Telephone Number (Cell) Home) (Other) State & Last 4 Digits of Driver License222s Number Last 4 Digits of Social Security Number Employer's Name & Address Employer's Telephone Number ASSISTANCE BENEFITSDo you or anyone residing in your household receive benefits from any of the following sources? (if so, pleasecheck those which apply) Temporary Assistance for Needy Families (TANF) Food Stamps Medicaid Social Security Income (SSI) Other 3.INCOME/EXPENSESTATEMENT Monthly Gross Income: Monthly Gross Income Spouse222s Monthly Gross Income (unless a marital offense) Other Monthly Earnings: Commissions, Bonuses, Interest Income, etc. Monthly Contributions from Other People Living in Household Monthly Unemployment / Worker222s Compensation, Social Security, Retirements, etc. Other Monthly 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) Credit Card Payment(s) Educational/Employment Expenses Other Expenses (be specific) Subtotal B.Child Support Payment(s)/Alimony (Subtotal) C.Exceptional Expenses (Subtotal) TOTAL MONTHLY EXPENSES (add subtotals from A, B & C monthly only) $ Total Gross Monthly Income Less Total Monthly Expenses $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com State of Alabama Unified Judicial System Form C-10 Page 2 of 2 Rev. 7/2019 AFFIDAVIT OF SUBSTANTIAL HARDSHIP (Section 12-19-70, Ala. Code 1975) Court Case Number 4.Assets Cash on Hand/Bank (or otherwise available such as stocks,bonds, certificates of deposit) Equity in Real Estate (value of properly 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 Assets 5.Affidavit/Request I swear or affirm that the answers are true and reflect my current financial status. I understand that a false statement oranswer to any question in the affidavit may subject me to the penalties of perjury. I authorize the court or its authorizedrepresentative to obtain records of information pertaining to my financial status from any source in order to verify informationprovide by me. I further understand and acknowledge that, if the court appoints an attorney to represent me, the court mayrequire me to pay all or part of the fees and expenses of my court-appointed counsel, in addition to all or part of the costsassociated with this case. Sworn to and subscribed before me this (Affiant222s Signature) day of, (Judge/Clerk/Notary) (Print or Type Name) $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com