Fill and Sign the Order of Expungement Alabama Law Enforcement Agency Form

State of Alabama Unified Judicial System F orm C -10 D 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)) T YPE 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. 1. IDENTIFICATION Full Name _______________________________________________________ Date of Birth _______________________ S pouse’s Full Name (if married) _________________________________________________________________________ Complete Home Address ________________________________________________________________________\ ______ ________________________________________________________________________\ __________________________ Number of People Liv ing in Household ___________________________________________________________________ Telephone Number (Cell) ________________________ (Hom e) _____________________ (Other) ___________________ S tate & Last 4 Digits of Driver Licens e’s Number __________________ Last 4 Digits of Social S ecurity Number _________ E mployer's Name & A ddres s ___________________________________ Employer's Telephone Number ________________ 2. ASSISTANCE BENEFITS Do you or anyone r esiding in your household receive benefits from any of the following sources? (if so, please c heck those which apply) Temporary Assistance for Needy Families (TANF) Food Stamps Medicaid Social Security Income (SSI) Other ________________________________ 3. INCOME/EXPENSE S TATEMENT M onthly 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 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) Cr edit Card Payment(s) _____________________ Educational/Employment Expenses Other Expenses (be specific) _ ________________ ______________________ __________________ _____ Subtotal B. Child S upport Payment(s)/Alimony (Subtotal) C. Exceptional Expenses (Subtotal) T OTAL MONTHLY EXPENSES (add subtotals from A, B & C monthly only) $______________ Total Gross Monthly Income Less Total Monthly Expenses $______________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $_________________ $______________ ___ $_____________ ___ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ $ ________ State of Alabama Unified Judicial System Form C -10 D 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 m e 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 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 th is C ourt reserves the right and may order reimbursement of docket fees. Done this _____________________________. (Date) ______________________________________________ (Signature of _____________________________, Judge) (Printed Name) $ _________________ $ _________________ $ _________________ $ _________________ $ _________________ $ _________________