State of Alabama Unified Judicial System Form C-10D Page 1 of 2 Rev. 7 /2019 A FFIDAVIT OF SUBSTANTIAL HARDSHIP AND ORDER (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-10D Page 2 of 2 Rev. 7/2019 AFFIDAVIT OF SUBSTANTIAL HARDSHIP AND ORDER (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 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 provide 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, in addition to all or part of the costs associated with this case. Sworn to and subscribed before me this (Affiant222s Signature) day of, (Judge/Clerk/Notary) (Print or Type Name) ORDER OF COURT SECTION II IT IS, THEREFORE, ORDERED AND ADJUDGED BY THE COURT AS FOLLOWS: Affiant is not indigent and the request for waiver of prepayment of docket fees is DENIED because this Court finds that the Affiant has the resources to pay the docket fees without substantial hardship as follows: . The prepayment of docket fees is waived and taxed as costs at the conclusion of the case because this Court finds that payment of the docket fees will constitute a substantial hardship for the reason that the Affiant has: an income level at or below 125% of the United States poverty level as defined by the most recently revised poverty income guidelines published by the United States Department of Health and Human Services; an income level greater than 125%, but at or below 200%, of the more recently revised poverty income guidelines published by the United States Department of Health and Human Services. IT IS FURTHER ORDERED AND ADJUDGED that this Court reserves the right and may order reimbursement of docket fees. Done this . (Date) (Signature of , Judge) (Printed Name) $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com