State of Alabama 
Unified Judicial System 

Form C-10-CRIMINAL  
Page 1 of  3   

  Rev.  9/2019 

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

Court Case Number 

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 

    I, because of financial hardship, am unable to pay the expungement petition administrative filing fee and request a 

these fees be waived.  

payment plan for this fee.   

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-CRIMINAL    
   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 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

___________day of_________________, __________ 

   _____________________________________ 
   (Affiant’s Signature) 

____________________________________________    
(Judge/Clerk/Notary)       

    _____________________________________ 

 (Print or Type Name) 

State of Alabama 
Unified Judicial System 

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

         STATE OF ALABAMA 

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

Court Case Number 

IN THE  __________________________________   COURT OF ___________________________________________, ALABAMA 

  (Circuit, District, or Municipal) 

                                      (Name of County or Municipality) 

 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)