N THE  __________________________________   COURT OF ________________________COUNTY, ALABAMA 
                                  (Circuit or District) 

                                                 (Name of County) 

STYLE OF CASE: _________________________________ v. ___________________________________________________   

(Plaintiff(s)) 

(Defendant(s)) 

       I, because of financial hardship, am unable to pay the fees and costs in this case.  I request that payment of these fees and 

costs be waived initially and taxed as costs at the conclusion of the case.    

Court Case Number 

   

AFFIDAVIT OF SUBSTANTIAL 
HARDSHIP AND ORDER 
(Request to Waive Filing Fees) 

State of Alabama 
Unified Judicial System 

orm C-10-CIVIL      

Page 1 of 3     Rev.  9/2019 

          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 ________________ 
 

ome 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 $__________________. 

2. 

 ASSISTANCE BENEFITS 

  S

1. 

IDENTIFICATION 

AFFIDAVIT 

 

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                                     $ _________ 

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.)                       $______________ 
 

  

  

  

 

 

  F

  I

 

 

   

 

  State of Alabama 
  Unified Judicial System 

  Form C-10-CIVIL 
  Page 2 of 3   Rev. 9/2019 

  AFFIDAVIT OF SUBSTANTIAL HARDSHIP AND ORDER 

 (Request to Waive Filing Fees) 

Court Case Number 

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

___________day of_________________, __________ 

   _____________________________________ 
   (Affiant’s Signature) 

____________________________________________    
(Judge/Clerk/Notary)       

    _____________________________________ 

 (Print or Type Name) 

ourt Case Number 

  C

 
ORDER ON AFFIDAVIT OF  
SUBSTANTIAL HARDSHIP 
(Request to Waive Filing Fees) 

State of Alabama 
Unified Judicial System 

orm C-10-CIVIL          
Page 3 of 3     Rev.  9/2019 

 

  F

IN THE  __________________________________   COURT OF ___________________________________________, ALABAMA 
                             (Circuit or District) 

                                                                   (Name of County or Municipality) 

_____________________________________________________ v. _____________________________________________   
 
                                                                                               
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 Court finds that the Affiant is NOT INDIGENT and the Affiant’s income is not within the United States poverty 

guidelines or the Affiant has the resources to pay for the requested items without substantial hardship: 
______________________________________________________________________________________________. 

 The case or situation is not one for which the request is applicable. 
 Other (please specify):__________________________________________________________________________ 
______________________________________________________________________________________________. 

The Affiant is INDIGENT. Therefore, the prepayment of filing fees and costs is hereby waived, and these fees and costs 

         

shall be taxed at the conclusion of the case.   
 

 Other (please specify): ____________________________________________________________________________ 
      ______________________________________________________________________________________________. 

                                                                                         
IT  IS FURTHER ORDERED AND ADJUDGED that the court reserves the right and may order reimbursement of expenses, fees, and costs. 

                                        (Date)                                                               ______________________________________________ 
                                                                                                                (Signature of _____________________________, Judge) 
                                                                                                                                                  (Printed Name) 

one this _____________________________. 

  D

             The request is DENIED.