Court Case Number 

State of Alabama 
Unified Judicial System 

Form C-10-JUVENILE  
Page 1 of  3   

  Rev.  9/2019 

AFFIDAVIT OF SUBSTANTIAL 
HARDSHIP AND ORDER 
(Request for Court-Appointed Attorney and/or 
Waiver of Fees) 

IN THE JUVENILE COURT OF ___________________________________________, ALABAMA 

 (Name of County) 

     In the Matter of 
      _________________________ v. ___________________________________ 

_, a child OR 

I am the  
        Accused       
        Parent, Guardian, or Custodian of the Child       
        Parent in the Juvenile Dependency/Termination-of-Parental-Rights Case 
        Petitioner in the Juvenile Dependency/Termination-of-Parental-Rights Case 

          I, because of financial hardship, am unable to hire an attorney and request that the court appoint one for me or my 

child.  

 I, because of financial hardship, am unable to pay the 

 filing fee for modification after dependency adjudication petition 

 filing fee for disabilities of nonage petition 

 filing fee for child-in-need-of-supervision, beyond-control-of-parent petition 

 filing fee for child-support action 

1.

IDENTIFICATION

AFFIDAVIT 

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 

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

AFFIDAVIT OF SUBSTANTIAL 
HARDSHIP AND ORDER 
(Request for Court-Appointed Attorney and/or 
Waiver of Fees) 

Court Case Number 

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 Costs        
          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

___________day of_________________, __________ 

   _____________________________________ 
   (Affiant’s Signature) 

____________________________________________    
(Judge/Clerk/Notary)       

    _____________________________________ 

 (Print or Type Name) 

ourt Case Number 

  C

State of Alabama 
Unified Judicial System 

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

 
AFFIDAVIT OF SUBSTANTIAL 
HARDSHIP AND ORDER 
(Request for Court-Appointed Attorney and/or 
Waiver of Fees) 

   

IN THE JUVENILE COURT OF ___________________________________________, ALABAMA 
                              

                                                     (Name of County) 

                                               In the Matter of  
                                       _____________________________ v. _________________________________ 

_, a child OR 

he 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, the 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. 

 Other (please specify): ___________________________________________________________ 

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

                                                                                                                                                                                             (name of attorney) 
appointed as counsel to represent ____________________________________. (Name) 
 

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. 

                                                                                            

 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. 

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

one this _____________________________. 

  D

  
              
 

The prepayment of the following fees is to be waived or as set out above: 

                    filing fee for modification after dependency adjudication petition  

                 filing fee for disabilities of nonage petition  

                 filing fee for child-in-need-of-supervision, beyond-control-of-parent petition  

                 filing fee for child-support action 

     

      F

   

 T