AFFIDAVIT OF SUBSTANTIAL HARDSHIP
Form C-10A Page 2 of 2 Rev.2/95
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
$________________
TOTAL MONTHLY EXPENSES (add subtotals from A & B monthly only)
$____________________
Total Gross Monthly Income Less total monthly expenses:
DISPOSABLE MONTHLY INCOME
$____________________
4.
LIQUID ASSETS:
C
ash on Hand/Bank (or oth
erwise 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 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 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,
Sworn to and subscribed before me this
________________________________________________
Affiant’s Signature
_________ day of ___________________, __________
_____________________________________________
_________________________________________________
Judge/Clerk/Notary
Print or Type Name
1
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