Affidavit of Financial Hardship Template: Income & Expenses

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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: $________

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: $________

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): $________

Bank Account Balance: $________

Vehicle Value (if any): $________

Other Assets (describe): $________

Debts and Liabilities:

Credit Card Debt: $________
Loans: $________
Other Debts (describe): $________

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 & Expenses

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Reviewed July 2026 Free download, PDF & DOCX

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.