ORS 652.520 Form of statement of wage claim

The statement to be presented under ORS 652.510 shall be substantially in the following form: __________________________________________ State of Oregon ) ) ss. County of , ) 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 . __________________________________________