A demand shall be in the following form:
     “Demand is hereby made upon an assignment of salary, wages, commissions or other compensation for services, executed by …. and delivered to …. on (insert date), to secure a debt contracted on (insert date).
     The total amount of the debt is $….. Payments in the amount of $…. have been made. The duration of the contract is …. months. There is now due and owing without acceleration the sum of $…., the last payment having been made on (insert date).
     The employee herein named has been in default in his payments in the amount of $…., of which $…. has been due and owing for more than 40 days.
     Unless you have received a written notice from the employee herein named revoking the wage assignment, you are required by law to make payment in accordance with such assignment. …., first being duly sworn, deposes and says that the facts stated in the demand above are true and correct; and further deposes and says that he (or his principal, if he is an agent for the assignee) has not received notice from the debtor that he or she is revoking the wage assignment.
     Payments must be made until the total amount due under the assignment is paid or until the employee revokes the wage assignment.

    Subscribed and sworn to before me on (insert date).