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

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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__.

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