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: __________________________