Fill and Sign the In the Court of Alabama 481195137 Form

State of Alabama Unified Judicial System Form C-1 0A Page 1 of 2 Rev. 7/2019 AFFIDAVIT OF SUBST ANTIAL HARDSHIP 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. T YPE OF PROCEEDING: ___ CIVIL/JUVENILE/CHILD-SUPPORT (CV, DV, DR, SM, JU, CS) CASE -- I, because of financial hardship, am unable to pay the fees and costs in this case. I request that payment of these fees and costs be waived initially and taxed as costs at the conclusion of the case. (Note: This form does not apply to DOCKET fees in CV, DV, DR, and SM cases. Form C-10D should be completed to request a waiver of prepayment of th ese docket fees). CRIMINAL (CC, DC, TR, Municipal) CASE -- I, because of financial hardship, am unable to hire an attorney and request that the court appoint one for me and/or am unable to pay the fees and costs in this case and request that payment of these fees and costs be waived initially and taxed as costs at the conclusion of the case. CHARGE(S): _____ __________________________ APPEALED/POST-CONVICTION CASE -- I, because of financial hardship, am unable to hire an attorney and request that the court appoint one for me. (Note: Relating to appealed cases, this box only applies to appeals to the Alabama Court of Criminal Appeals or the Alabama Court of Civil Appeals or petitions for writs of certiorari to the Supreme Court of Alabama). DELINQUENCY/CHILD-IN -NEED OF SUPERVISION (JU) CASE -- I, because of financial hardship, am unable to hire an attorney to represent me/my child. I request that an attorney be appointed to represent me/my child. CHARGE(S): _ _________________________ DEPENDENCY/TERMINATION-OF -PARENTAL-RIGHTS (JU) CASE -- I, be cause of financial hardship, am unable to hire an attorney to represent me. I request that an attorney be appointed to represent me. CIVIL/JUVENILE/CHILD-SUPPORT (CV, DV, DR, SM, JU, CS) CASE (such as paternity, contempt, waiver of parental consent for abortion, juvenile mental commitment) -- I, because of financial hardship, am unable to hire an attorney to represent me. I request that an attorney be appointed to represent me. AFFIDAVIT SECTION 1. 1. IDENTIFICATION Full N ame _ ______________________________________________________ Date of Birth _______________________ Spouse’s Full Name (if married) __ _______________________________________________________________________ Complete Home A ddress _ _____________________________________________________________________________ _ _________________________________________________________________________________________________ Number of People Living in Household ___________________________________________________________________ Telephone Number (Cell) _____________________ (Home) _ __________________ (Other) _ _______________________ State & Last 4 Digits of Driver License’s Number __________________ Last 4 Digits of Social Security Number _________ Employer's Name & Addre ss ___________________________________ Employer's Telephone Number ________________ 2. ASSISTANCE BENEFITS D o you or anyone residing in your household receive benefits from any of the following sources? ( if so, please check those which apply) Temporary Assistance for Needy Families (TANF) Food Stamps Medicaid Social Security Income (SSI) Other _ _______________________________ 3. INCOME/EXPENSE STATEMENT Monthly Gross Income: Monthly Gross Income $ _________ Spouse’s 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 / Worker’s Compensation, Social Security, Retirements, etc . $ _________ Other Monthly Income (be specific ) $ _________ TOTAL MONTHLY GROSS INCOME $ _________ State of Alabama Unified Judicial Sy stem Form C-1 0A Page 2 of 2 Rev. 7/ 2019 AFFIDAVIT OF SUBSTANTIAL HARDSHIP Court Case Number 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)_________________ __ ______________________________________ S ubtotal B. Child S upport Payment(s)/Alimony (Subtotal) C. E xceptional Expenses (Subtotal) TO TAL MONTHLY EXPENSES (add subtotals from A, B & C monthly only) $ ______________ Total Gross Monthly Income Less Total Monthly Expenses $______________ 4. Assets Cash o n Hand/Bank (or otherwise available such as stocks, bonds, certificates of deposit) Equit y 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 sw ear 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. Swor n to and subscribed before m e this _____________________________________ (Affiant’s Signature) ___________day of _________________, __________ _____ _______________________________________ _____________________________________ (Judge/Clerk/Notary) (Print or Type Name) $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $_____________ ____ $______________ ___ $_________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________