Oregon Revised Statutes Human Services; Juvenile Code; Corrections § 416.560

The form of the notice required by ORS 416.550 (1) shall be substantially as follows:

Notice is hereby given that the __________ has rendered assistance to __________, a person who was injured on or about the ___ day of __________ in the city of __________ and State of __________, and the __________ hereby asserts a lien to the extent provided in ORS 416.510 to 416.610, for the amount of such 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 public body, agency or commission 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 Director of __________ or designee; that I have read the foregoing notice of lien and know the contents thereof and believe the same to be true.