ORS 416.560 Form of notice of lien

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.

Department of Human Services/Oregon Health Authority

by ____________,

Director of ________ or designee.

State of Oregon, )

) ss.

County of ______ )

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.

____________

Subscribed and sworn to before me this ___ day of ______, ______. ____________, Notary Public.

______________________________________________________________________________