State of Alabama Unified Judicial System Form C-10 Page 1 of 2 Rev. AFFIDAVIT OF SUBSTANTIAL HARDSHIP AND ORDER Case Number IN THECOURT OF , ALABAMA (Circuit, District, or Municipal) (Name of County or Municipality) STYLE OF CASE: v. Plaintiff(s) Defendant(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) 226I 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. IDENTIFICATIONFull name Date of Birth Spouse222s full name (if married) Complete home address Number of people living in household Home telephone number Occupation/Job Length of employment Driver222s icense umber ocial Security NumberEmployer Employer222s telephone numberEmployer222s address ASSISTANCE BENEFITSDo you or anyone residing in your household receive benefits from any of the following sources? (if so, please check those whichapply)AFDC Food Stamps SSI Medicaid OtherINCOME/EXPENSE STATEMENTMonthly Gross Income: Monthly Gross Income$ Spouse222s Monthly Gross Income (unless a marital offense) Other Earnings: Commissions, Bonuses, Interest Income, etc, Contributions from Other People Living in Household Unemployment/Workmen222s 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.FormsWorkFlow.com Form C-10 Page 2 of 2 Rev. AFFIDAVIT OF SUBSTANTIAL HARDSHIP AND ORDER Monthly Expenses:(cont222d page1) Credit Card Payment(s) Educational/Employment Expenses Other Expenses (be specific) Sub-TotalA $ B.Child Support Payment(s)/Alimony$ Sub-TotalB $ C.Exceptional Expenses$TOTAL MONTHLY EXPENSES (add subtotals from A & B monthly only)$ Total Gross Monthly Income Less total monthly expenses: DISPOSABLE MONTHLY INCOME$ 4.LIQUID ASSETS:Cerwise available such as stocks, bonds, certificates of deposit)$ ash on Hand/Bank (or othEquity 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 LIQUID ASSETS$ 5.Affidavit/RequestI swear or affirm that the answers are true and reflect my current financial status. I understand that a false statement or answer toany question in the affidavit may subject me to the penalties of perjury, I authorize the court or its authorized representative to obtainrecords of information pertaining to my financial status from any source in order to verify information provide by me. I furtherunderstand and acknowledge that, if the court appoints an attorney to represent me, the court may require me to pay all or part ofthe fees and expenses of my court-appointed counsel, Sworn to and subscribed before me this Affiant222s Signature day of , Judge/Clerk/NotaryPrint or Type Name ORDER OF COURT SECTION II IT IS THEREFORE, ORDERED, AND ADJUDGED BY THE COURT AS FOLLOWS: Affiant is not indigent and request is DENIED. Affiant is partially indigent and able to contribute monetarily toward his/her defense; therefore defendant is ordered to pay $ towards the anticipated cost of appointed counsel. Said amount is to be paid to the clerk of court or as otherwise ordered and disbursed as follows: Affiant is indigent and request is GRANTED. The prepayment of docket fees is waived. IT IS FURTHER ORDERED AND ADJUDGED that is hereby appointed as counsel to represent affiant. IT IS FURTHER ORDERED AND ADJUDGED that the court reserves the right and may order reimbursement of attorney222s fees and expenses, approved by the court and paid to the appointed counsel, and costs of court. Done this day of Judge American LegalNet, Inc. www.FormsWorkFlow.com State of Alabama Unified Judicial System Form C-10A Page 1 of 2 Rev./ AFFIDAVIT OF SUBSTANTIAL HARDSHIPCase Number IN THECOURT OF , ALABAMA (Circuit, District, or Municipal) (Name of County or Municipality) STYLE OF CASE: v. Plaintiff(s) Defendant(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) 226I 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 appointone for my child/me AFFIDAVIT SECTION 1. IDENTIFICATIONFull name Date of Birth Spouse222s full name (if married) Complete home address Number of people living in household Home telephone number Occupation/Job Length of employment Driver222s license number *Social Security NumberEmployer Employer222s telephone numberEmployer222s address ASSISTANCE BENEFITSDo you or anyone residing in your household receive benefits from any of the following sources? (if so, please check those whichapply) AFDC Food Stamps SSI Medicaid Other3.INCOME/EXPENSE STATEMENTMonthly Gross Income: Monthly Gross Income$ Spouse222s Monthly Gross Income (unless a martial offense) Other Earnings: Commissions, Bonuses, Interest Income, etc, Contributions from Other People Living in Household Unemployment/Workmen222s 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.FormsWorkFlow.com Form C-10A Page 2 of 2 Rev. AFFIDAVIT OF SUBSTANTIAL HARDSHIP Monthly Expenses:(cont222d page1) Credit Card Payment(s) Educational/Employment Expenses Other Expenses (be specific) Sub-TotalA $ B.Child Support Payment(s)/Alimony$ Sub-TotalB $ C.Exceptional Expenses$TOTAL MONTHLY EXPENSES (add subtotals from A & B monthly only)$ Total Gross Monthly Income Less total monthly expenses: DISPOSABLE MONTHLY INCOME$ 4.LIQUID ASSETS:Cerwise available such as stocks, bonds, certificates of deposit)$ ash on Hand/Bank (or othEquity 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 LIQUID ASSETS$ 5.Affidavit/RequestI swear or affirm that the answers are true and reflect my current financial status. I understand that a false statement or answer toany question in the affidavit may subject me to the penalties of perjury, I authorize the court or its authorized representative to obtainrecords of information pertaining to my financial status from any source in order to verify information provide by me. I furtherunderstand and acknowledge that, if the court appoints an attorney to represent me, the court may require me to pay all or part ofthe fees and expenses of my court-appointed counsel, Sworn to and subscribed before me this Affiant222s Signature day of , Judge/Clerk/NotaryPrint or Type Name American LegalNet, Inc. www.FormsWorkFlow.com S