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Affidavit Of Substantial Hardship And Order C-10 - Alabama
| Affidavit Of Substantial Hardship And Order Form. This is a Alabama form and can be used in C-Series (Civil) Statewide . |
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State of Alabama Case NumberUnified Judicial System AFFIDAVIT OF SUBSTANTIAL Form C-10 Page 1 of 2 Rev. 2/95 HARDSHIP AND ORDER IN THE __________________________________ COURT OF ___________________________________, ALABAMA (Circuit, District, or Municipal) (Name of County or Municipality) STYLE OF CASE: _______________________________________ v. _______________________________________ Plaintiff(s) Defendant(s)TYPE OF PROCEEDING: ______________________ CHARGE(s) (if applicable): _____________________________ G CIVIL CASE-- I, because of substantial hardship, am unable to pay the docket fee and service fees in this case. I request that payment of these fees be waived initially and taxed as costs at the conclusion of the case. G 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. G CRIMINAL CASE-- I am financially unable to hire an attorney and request that the court appoint one for me. G 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 I. 1. IDENTIFICATION Full name ___________________________________________________________________ Date of birth _____________________ Spouses full name (if married) _________________________________________________________________________________ Complete home address _______________________________________________________________________________________ ____________________________________________________________________________________________________________ Number of people living in household ___________________________________________________________________________ Home telephone number __________________________________________ Occupation/Job ____________________________ Length of employment ________________________________________________ Drivers license number ______________________________ *Social Security Number _____________________________________ Employer _________________________________________ Employers telephone number __________________________________ Employers 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.) G AFDC G Food Stamps G SSI G Medicaid G Other ______________________________________________3. INCOME/EXPENSE STATEMENT Monthly Gross Income: Monthly Gross Income $ _________________ Spouses Monthly Gross Income (unless a marital offense) _________________ Other Earnings: Commissions, Bonuses, Interest Income, etc. _________________ Contributions from Other People Living in Household _________________ Unemployment/Workmens Compensation, Social Security, Retirements, etc. _________________ Other 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) ________________ *OPTIONAL <<<<<<<<<********>>>>>>>>>>>>> 2 AFFIDAVIT OF SUBSTANTIAL HARDSHIP AND ORDER Form C-10 Page 2 of 2 Rev. 2/95 Monthly Expenses: (contd page 1) 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 $ ________________ TOTAL MONTHLY EXPENSES (add subtotals from A & B monthly only) $ _______________ Total Gross Monthly Income Less total monthly expenses: DISPOSABLE MONTHLY INCOME $ _______________4. LIQUID ASSETS: Cash on Hand/Bank (or otherwise available such as stocks, bonds, certificates of deposit) $ _______________ Equity in Real Estate (value of property 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? G Yes G 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 representative to obtain records of information pertaining to my financial status from any source in order to verify information provided 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. Sworn to and subscribed before me this ______________________________________________ ___________ day of _________________, _________. Affiants Signature ____________________________________________ ______________________________________________ Judge/Clerk/Notary Print or Type Name ORDER OF COURT SECTION II. IT IS THEREFORE, ORDERED, AND ADJUDGED BY THE COURT AS FOLLOWS: G Affiant is not indigent and request is DENIED. G Affiant is partially indigent and able to contribute monetarily toward his/her defense; therefore defendant is ordered to pay $ ____________ toward the anticipated cost of appointed counsel. Said amount is to be paid to the clerk of court or as otherwise ordered and disbursed as follows: ____________________________________________________________________________ G Affiant is indigent and request is GRANTED. G 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 court reserves the right and may orde
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