Form C-10a - Affidavit Of Substantial Hardship Form - State Of Alabama Unified Judicial System
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1
2State of Alabama
Case Number
Unified Judicial System
AFFIDAVIT OF SUBSTANTIAL HARDSHIP
Form C-10A
Page 1 of 2
Rev.2/95
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):__________________________________
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.
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 __________________________________________________
Driver’s license number __________________________________ *Social Security Number_________________________________________
Employer_____________________________________________ Employer’s telephone 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 martial offense)
________________
Other Earnings: Commissions, Bonuses, Interest Income, etc,
________________
Contributions from Other People Living in Household
________________
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, Water, etc
________________
Food
________________
Clothing
________________
Health Care/Medical
________________
Insurance
________________
Car Payment(s)/Transportation Expenses
________________
Loan Payment(s)
________________
*OPTIONAL
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