Oregon Revised Statutes Procedure in Criminal Matters Generally § 147.289

The form of the notice of lien required by ORS 147.287 shall be substantially as follows:

  Notice is given by this form that the Department of Justice has provided assistance to __________, a person who was injured on or about the __ day of __________ in the city of __________ and State of __________, and the Department of Justice asserts a lien to the extent provided in ORS 147.285 for the amount of the assistance upon any amount due and owing __________ (name of injured person) under a judgment, settlement or compromise from __________ alleged to have caused such injuries and from any other person or entity liable for the injury or obligated to compensate the injured person on account of such injuries.

I, __________, being first duly sworn on oath say: That I am the Attorney General or designee; that I have read the foregoing notice of lien and know the contents of the notice of lien and believe the contents to be true.

Subscribed and sworn to before me this __ day of __________, __________.