Oregon Revised Statutes Labor and Employment; Unlawful Discrimination § 652.520

The statement to be presented under ORS 652.510 shall be substantially in the following form:

I, ________, being first duly sworn, say that ________ is indebted to me in the sum of _____ dollars over and above all just credits and setoffs, on account of work, services and labor performed by me for the said ________, upon the following terms and conditions, to wit: That I was employed by the said ________ on or about the _____ day of ________, 2__, to work (here describe character of work) at the rate of _____ dollars per month (or for a reasonable consideration for such work), and that under said contract I began to work on the _____ day of ________, 2__, and between that day and the _____ day of __________, 2__, I performed work, services and labor _____ days, amounting to the sum of _____ dollars (or the reasonable value of _____ dollars); that the said ________ has paid me on account of the said labor the sum of _____ dollars, and no more; and that there is now due me, the sum of _____ dollars, over and above all just credits and offsets; and that during the 90 days next preceding the _____ day of ________, 2__, I had performed _____ days' labor under said contract, amounting to the sum of _____ dollars (or that said services were reasonably worth the sum of _____ dollars); and that, applying all the credits above stated, there is due me from the said __________, on account of labor for the said 90 days, the sum of _____ dollars, and no more; claim as due me.

Subscribed and sworn to before me this _____ day of ________, 2__.