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State of Alabama Unified Judicial System Fo rm C-10 Page 1 of 2 Rev. 5/18 AFFIDAVIT OF SUBSTANTIAL HARDSHIP AND ORDER Case Number IN THE_______________________________________CO URT OF ________________________________________, ALABAMA (Circuit, District, or Municipal) (Name of County or Municipality) STYLE OF CA SE: _____________________________________________v. ___________________________________________ Plaintiff(s) Defendant(s) TYPE OF PROCEEDIN G:___________________________CHARGE(s) (if applicable):__________________________________ CIVIL CASE-- I, because of substantial hards hip, am unable to pay the docket fee and service fees in this case. I request that payment of these f ees be waived initially and taxed as co sts 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 AFFIDA VIT 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 ___\ _______________________________________________ Last 4 of Driver’s License Number __________________________ Last 4 of *Social Security Number_______________________________ Employer_____________________________________________ Employer’s tele\ phone 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 m arital offense) ________________ Other Earnings : Commissions, Bonuses, Interest Income, etc, ________________ Contributions from Other People Living in Hous ehold________________ 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, W ater, etc ________________ Food \ ________________ Clothing ________________ Health Care/Medical ________________ Insurance ________________ Car Payment(s)/Transportation Expenses ________________ Loan Payment(s) ________________ *OPTIONAL Form C-10 Page 2 of 2 Rev. 5/18 AFFIDAVIT OF SUBSTANTIAL HARDSHIP AND ORDER 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 $________________ Sub-Total B $____________________ C. Exceptional Expenses $________________ TOTA L MONTHLY EXPENSES (add subtotals from A & B monthly only) $____________________ Total Gross Monthly Income Less total monthly expenses: DISPOSABLE MONTHLY INCOME$____________________ 4. LIQUID ASSETS: C erwise available such as stocks, bonds, certificates of deposit) $_________________ ash on Hand/Bank ( or oth 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 w hat you owe) Other ( be specific) Do you ow n anything else of value? Yes No (land, house, boat, TV, stereo, jewelry) _________________ If so, describe _____________________________________ _________________________________________________ TOTAL LIQUID 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 representativ e to obtain records of information pertaining to my financial status from any source in order to verify information provide by me. I furthe r understand and acknow ledge that, if the court appoints an attorney to represent me, the court may require me to pay all or part of the fees and ex penses of my court-appointed counsel, Sworn to and subscribed before me this ________________________________________________ Affiant’s 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 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 am ount 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 c ourt reserves the right and may order reimbursement of attorney’s fees and expenses, approved by the court and paid to the appointed counsel, and costs of court. Done this________________________ day of ________________________________________ ________________________________________________ Judge State of Alabama Unified Judicial System Form C-10A Page 1 of 2Rev. 5/1 8 AFFIDAVIT OF SUBSTANTIAL HARDSHIP Case Number IN THE_______________________________________CO URT OF ________________________________________, ALABAMA (Circuit, District, or Municipal) (Name of County or Municipality) STYLE OF CA SE: _____________________________________________v. ___________________________________________ Plaintiff(s) Defendant(s) TYPE OF PROCEEDIN G:___________________________CHA RGE(s) (if applicable):__________________________________ CIVIL CASE-- I , because of substantial hards hip, am unable to pay the docket fee and service fees in this case. I request that payment of these f ees be waived initially and taxed as co sts 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 ___\ _______________________________________________ Last 4 of Driver’s license number __________________________ Last 4 of *Social Security Number_________________________________ Employer_____________________________________________ Employer’s tele\ phone number_____________________________________ Employer’s address __________________________________________________\ ________________________________________________ ________________________________________________________________________\ __________________________________________ 2. ASSISTANCE B ENEFITS 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 martial offense) ________________ Other Earnings : Commissions, Bonuses, Interest Income, etc, ________________ Contributions from Other People Living in Hous ehold________________ Unemploy ment/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, Wa ter, etc________________ Food \ ________________ Clothing ________________ Health Care/Medical ________________ Insurance ________________ Car Payment(s)/Transportation Expenses ________________ Loan Pay ment(s) ________________ * OP TIONAL Form C-10A Page 2 of 2 Rev. 5/18 AFFIDAVIT OF SUBSTANTIAL HARDSHIP Monthly Expenses:(cont’d page1) Credit Card Pay ment(s)___________ _____ Educational/Employ ment Expenses________________ Other Expenses (be specific) _____________________ ________________ _____________________________________________ ________________ Sub-Total A $_ ___________________ B. Child Support Pay ment(s)/Alimony $___________ _____ Sub-Total B $_ ___________________ C. Exceptional Expenses $________________ TO TAL MONTHLY EXPENSES (add subtotals from A & B monthly only) $____________________ Total Gross Monthly Income Less total monthly expenses: DISPOSA BLE MONTHLY INCOME $____________________ 4. LIQ UID ASSETS: C er wise available such as stocks, bonds, certificates of deposit) $_________________ ash on Hand/Bank ( or oth Equity in Real Estate (value of properly less what you ow e)_________________ Equity in Personal Property , etc. (such as the value of motor vehicles, stereo, VCR, furnishing, jew elry , tools,_________________ guns, less w hat you owe) Other ( be specific) Do y ou own anything else of value? Yes No (land, house, boat, TV, stereo, jew elry) __________ _______ If so, describe _____________________________________ _________________________________________________ TO TAL LIQUID A SSETS $____________________ 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 answ er to any question in the affidavit may subject me to the penalties of perjury, I authorize the court or its authorized representativ e to obtain records of information pertaining to my financial status from any source in order to verify information provide by me. I furthe r understand and acknow ledge that, if the court appoints an attorney to represent me, the court may require me to pay all or part of the fees and ex penses of my court-appointed counsel, Sw orn to and subscribed before me this ________________________________________________ Affiant’s Signature _________ day of ___________________, __________ _____________________________________________ __________________________________ _______________ Judge/Clerk/Notary Print or Ty pe Name State of Alabama Unified Judicial System Form C-10BRev. 5/18 ORDER APPOINTING COUNSEL (INDIGENT) Case Number IN THE___________________________________________COURT OF ______________\ ________________________________, ALABAMA ( Circuit, District, or M unicipal) (Name of County or Municipality) STYLE OF CASE: ______________________________________________v. ___________________________________________________ Plaintiff(s) Defendant STATE OF ALABAMA Municipality of _________________________________________________ v. ________________________________________________ Defendant IN THE MA TTER OF _______________________________________________________________________\ ______, a child IT IS, THEREFORE, ORDERED AND ADJUDGED BY THIS COURT AS FOLLOWS: Affiant is not indigent and request is DENIED. Affiant is partially indigent and able to contribute monetarily towards his defense; therefore, defendant is ordered to pay $_________________ toward the anticipated cost of appointed counsel. This 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. (Name of Attorney) IT IS FURTHER ORDERED AND ADJUDGED that the court reserves the right and may order reimbursement of attorney’s fees and expenses, approved by the court and paid to the appointed counsel, and costs of court. Done this________________________ day of ________________________________________, __________ ________________________________________________ Judge