Affidavit of Substantial Hardship and Order

State of Alabama Court Case Number
Unified Judicial System

AFFIDAVIT OF SUBSTANTIAL
HARDSHIP AND ORDER
Form C-10-CRIMINAL (Request for Court-Appointed Attorney and/or
Page 1 of 3 Rev. 9/2019 Waiver of Fees)
IN THE __________________________________ COURT OF ___________________________________________, ALABAMA
(Circuit, District, or Municipal) (Name of County or Municipality)
STATE OF ALABAMA
MUNICIPALITY OF ___________________________ v. _____________________________________________, Defendant
I, because of financial hardship, am unable to hire an attorney and request that the court appoint one for me.
I, because of financial hardship, am unable to pay for ignition interlock device fees in this case and request that
these fees be waived.
I, because of financial hardship, am unable to pay the expungement petition administrative filing fee and request a
payment plan for this fee.
AFFIDAVIT
1. IDENTIFICATION
Full Name _______________________________________________________ Date of Birth _______________________

Spouse’s Full Name (if married) _________________________________________________________________________
Complete Home Address ______________________________________________________________________________
__________________________________________________________________________________________________
Total Number of People I am Supporting Financially in Household Including Myself ________________________________
Telephone Number (Cell) _____________________ (Home) ___________________ (Other) ________________________
State & Last 4 Digits of Driver License’s Number __________________ Last 4 Digits of Social Security Number _________
Employer's Name & Address ___________________________________ Employer's Telephone Number ________________
2. ASSISTANCE BENEFITS
Some of the residents in my household or I receive benefits from any of the following sources (check those which
apply)
Temporary Assistance for Needy Families (TANF) Food Stamps Medicaid
Social Security Income (SSI) Disability Other:______________________________________
The monthly value of these benefits combined is $__________________.
3. INCOME/EXPENSE
STATEMENT
Monthly Gross Income:

My monthly gross income is $ _________
My spouse’s monthly gross income (unless a marital offense) is $ _________
My other monthly earnings (commissions, bonuses, interest income, etc.) are $ _________
The combined monthly income received by other members of my household is $ _________
Monthly Unemployment / Worker’s Compensation, Social Security, Retirements, etc. $ _________
Child Support Payment(s)/Alimony Received $ _________
Other Monthly Income (be specific): _________________________________ $ _________
3a. TOTAL MONTHLY GROSS INCOME $ _________
State of Alabama
Unified Judicial System Court Case Number
AFFIDAVIT OF SUBSTANTIAL
HARDSHIP AND ORDER
Form C-10-CRIMINAL
(Request for Court-Appointed Attorney and/or
The monthly expenses I pay are:

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 $___________________
Cell Phone Expenses $___________________
Other Expenses (be specific): _________________
________________________________________ $___________________
3b. Subtotal $_____________
3c. Child Support Payment(s)/Alimony (Subtotal) $_____________
3d. Exceptional Expenses (Subtotal) $______________
3e. TOTAL MONTHLY EXPENSES (Add totals from 3b, 3c., & 3d. monthly only) $______________
Total Monthly Gross Income (3a.) minus Total Monthly Expenses (3e.) $______________
4. Assets
My assets are as follows:
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, TV, electronics, 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
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, in addition to all or part of the costs
associated with this case.
Sworn to and subscribed before me this

_____________________________________
(Affiant’s Signature)
___________day of_________________, __________
____________________________________________ _____________________________________
(Judge/Clerk/Notary) (Print or Type Name)
State of Alabama
Unified Judicial System Court Case Number
ORDER ON AFFIDAVIT OF
SUBSTANTIAL HARDSHIP
Form C-10-CRIMINAL
(Request for Court-Appointed Attorney and/or
IN THE __________________________________ COURT OF ___________________________________________, ALABAMA

(Circuit, District, or Municipal) (Name of County or Municipality)
STATE OF ALABAMA
MUNICIPALITY OF ___________________________ v. _____________________________________________, Defendant
The Court has considered the Affiant’s testimony, his or her poverty level as measured by the United States poverty guidelines and
the potential for substantial hardship that payment by the Affiant would cause. IT IS, THEREFORE, ORDERED AND ADJUDGED
BY THE COURT AS FOLLOWS:
The request is DENIED.

The Court finds that the Affiant is NOT INDIGENT pursuant to § 15-12-1, et seq., Ala. Code 1975.
The case or situation is not one for which the request is applicable.
Other (please specify):__________________________________________________________________________
______________________________________________________________________________________________.
The Affiant is INDIGENT. Further, affiant has the following income level based on the United States poverty guidelines:
at or below 125%; or
greater than 125% but less than 200%. However, the Court finds that not providing indigent defense services would
cause the Affiant substantial hardship; or
greater than 200%. However, the Affiant is charged with a felony, and the Court finds that not providing indigent
defense services would cause the Affiant substantial hardship.
The following fees shall be assessed as follows:

Ignition interlock device fees are waived.
Payment of Expungement filing fees shall be waived and assessed at the conclusion of the case.
Other (please specify): _______________________________
The request for appointment of counsel is GRANTED, and ___________________________________ is hereby

appointed as counsel for the Defendant.
The Affiant is able to contribute monetarily toward payment of the fees of his or her appointed counsel and/or the fees
and costs of this case. Therefore, the Affiant is ordered to pay $ ____________ to the clerk of court for his or her
appointed attorney and $__________ toward his or her fees and costs. Said fees and costs shall be due as follows:
$______ monthly.
Other (please specify): ____________________________________________________________________________

______________________________________________________________________________________________.
IT IS FURTHER ORDERED AND ADJUDGED that the court reserves the right and may order reimbursement of attorney’s fees and other
expenses, fees, and costs.
Done this _____________________________.

(Date) ______________________________________________
(Signature of _____________________________, Judge)

(Printed Name)

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State of Alabama Court Case Number

Unified Judicial System

Full Name _________________________________ Date of Birth _

Monthly Gross Income:

The monthly expenses I pay are:

3b. Subtotal $_____________

3c. Child Support Payment(s)/Alimony (Subtotal) $_____________

3d. Exceptional Expenses (Subtotal) $______________

Total Assets $ _________________

Sworn to and subscribed before me this

IN THE COURT OF _________, ALABAMA

The request is DENIED.

The following fees shall be assessed as follows:

The request for appointment of counsel is GRANTED, and ___________________________________ is hereby

Other (please specify): ____________________________________________________________________________

Done this _____________________________.

(Signature of _____________________________, Judge)

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