State of Alabama Unified Judicial System Form C-10B Page 1 Rev. 6/2019 ORDER Court Case Number IN THE COURT OF , ALABAMA (Circuit, District, or Municipal) (Name of County or Municipality) STYLE OF CASE: v. (Plaintiff(s), State of Alabama, City of ) (Defendant(s)) OR In the Matter of , a child. IT IS, THEREFORE, ORDERED AND ADJUDGED BY THE COURT AS FOLLOWS: Affiant is not indigent and the request for appointment of counsel is DENIED. Affiant is not indigent and the request for waiver of prepayment of docket or other fees is DENIED because this Court finds that the Affiant has the resources to pay the docket or other fees without substantial hardship as follows: Affiant is indigent and the request for appointment of counsel is GRANTED 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 and because this Court finds that not providing indigent defense services in this case would cause the Affiant substantial hardship; an income level greater than 200 percent of the most recently revised poverty income guidelines published by the United States Department of Health and Human Services, the Affiant is charged with a felony, and because this Court finds that not providing indigent defense services in this case would cause the Affiant substantial hardship; Based on the forgoing, payment of the fees and costs will constitute a substantial hardship. the prepayment of fees and costs is waived and taxed as costs at the conclusion of the case because this Court finds that payment of the fees and costs will constitute a substantial hardship. IT IS FURTHER ORDERED AND ADJUDGED that is hereby appointed as counsel to represent the Affiant. IT IS (Name of Attorney) FURTHER ORDERED AND ADJUDGED that the court reserves the right and may order reimbursement of attorney222s fees and pre-approved expenses, filing and service fees, and court costs. Done this . (Date) (Signature of , Judge) (Printed Name) American LegalNet, Inc. www.FormsWorkFlow.com