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Affidavit of Financial Hardship Template: Income & Expense Proof
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Affidavit of Financial Hardship Template
IN THE [NAME OF COURT] COURT OF [COUNTY], [STATE]
Case No.: __________________________
In the Matter of:
Petitioner: __________________________
Respondent: __________________________
1. Personal Information
Full Name: __________________________
Address: __________________________
Phone: __________________________
Email: __________________________
Date of Birth: __________________________
Occupation: __________________________
Employer: __________________________
2. Statement of Financial Condition
I, [Full Name], being duly sworn, state that due to my current financial circumstances, I am unable to pay the required court fees or other financial obligations in this matter.
My current financial details are as follows:
Monthly Income:
Employment Income: $________
Other Income (e.g., benefits, child support, pensions): $________
Total Monthly Income: $________
Monthly Expenses:
Rent/Mortgage: $________
Utilities: $________
Food: $________
Transportation: $________
Childcare/Dependent Care: $________
Medical Costs: $________
Other Obligations (specify): $________
Total Monthly Expenses: $________
Assets:
Bank Account Balance: $________
Vehicle Value (if any): $________
Other Assets (describe): $________
Debts and Liabilities:
Credit Card Debt: $________
Loans: $________
Other Debts (describe): $________
3. Statement of Hardship
I am experiencing financial hardship because:
[Explain reasons for hardship — e.g., loss of employment, medical emergency, reduction in income, or high dependent care costs.]
I respectfully request the Court to:
☐ Waive my court filing fees
☐ Approve a payment plan
☐ Reduce or suspend required payments
☐ Provide other financial relief as deemed appropriate
4. Declaration and Oath
I certify under penalty of perjury that the information contained in this Affidavit of Financial Hardship is true and complete to the best of my knowledge. I understand that providing false information may result in legal penalties.
Signature: __________________________
Printed Name: __________________________
Date: __________________________
5. Notary Acknowledgment
State of __________________________
County of __________________________
Subscribed and sworn to before me on this _____ day of __________, 20_____, by __________________________.
Signature of Notary Public: __________________________
Printed Name: __________________________
Commission Expires: __________________________
Seal: __________________________
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Affidavit of Financial Hardship Template: Income & Expense Proof
Affidavit of Financial Hardship FAQ
What is an Affidavit of Financial Hardship?
An Affidavit of Financial Hardship is a sworn legal document in which an individual certifies under oath that they are unable to meet financial obligations such as court fees, fines, or other payments due to limited income or financial challenges. It allows the court or agency to assess eligibility for fee waivers, payment plans, or reduced obligations.
Why is an Affidavit of Financial Hardship important?
It ensures access to justice by allowing financially constrained individuals to participate in legal proceedings without being hindered by costs. Courts often require such affidavits to verify the legitimacy of a fee waiver or financial assistance request.
When should you use an Affidavit of Financial Hardship?
Use this form when you need to request relief from filing fees, fines, or support payments, especially in divorce, custody, or family support cases. It is typically filed at the same time as the main petition or motion requiring payment.
What should an Affidavit of Financial Hardship include?
It should include personal identifying information, household income, assets, monthly expenses, debts, and a signed statement under oath confirming the accuracy of the information provided.
Is the Affidavit of Financial Hardship legally binding?
Yes. Because it is signed under penalty of perjury, false statements can result in legal penalties, including fines or contempt of court.
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