ORS § 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.
Department of Justice
by ____________,
Attorney General or designee.
State of Oregon, | ) |
) | ss. |
County of ______ | ) |
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 ______, ______.
____________, Notary Public.
______________________________________________________________________________
ORS 147.289