ORS 652.520
Form of statement of wage claim

The statement to be presented under ORS 652.510 (Payment of wage claims by receivers, assignees or court) 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__.


Last accessed
Jun. 26, 2021