(2) A debt calculation form must be in substantially the following form:

______________________________________________________________________________

________COURT

COUNTY OF ________

______ )

Plaintiff, ) DEBT

) CALCULATION

vs. ) Case No. _____

)

______ )

Defendant. )

TO: ________(Debtor).

The following amounts have been calculated to be owing from you to ________ (Creditor). The amounts are owed by reason of:

__ A judgment entered against you dated_____, 2__, in Case No._____, ______Court, ______County.

__ Other debt subject to garnishment under the law (provide details):

______________________

______________________

THE COURT ADMINISTRATOR HAS NOT CALCULATED ANY AMOUNTS FOR THE PURPOSE OF THIS FORM AND IS NOT LIABLE FOR ERRORS IN THIS FORM OR IN THE WRIT OF GARNISHMENT MADE BY THE CREDITOR OR GARNISHOR.

Original Debt Amount $______

+ Pre-adjudication Interest $______

+ Attorney Fees $______

+ Cost Bill $______

+ Post-adjudication Interest $______

+ Delivery Fee for Writ $______

+ Sheriff’s Fees other

than Delivery Fees $______

+ Other (Explain. Attach

additional sheets

if necessary.)

______ $______

______ $______

______ $______

______ $______

Total "Other"

from additional

sheets (if used)

+ Past Writ Issuance Fees $______

+ Past Delivery Fees $______

+ Transcript and Filing

Fees for Other Counties $______

= Subtotal $______

LESS Payments Made on Debt $(______)

= Total Amount Required to

Satisfy Debt in Full $______

NOTE: INSERTING ITEMS AND AMOUNTS NOT LAWFULLY SUBJECT TO COLLECTION BY GARNISHMENT MAY RESULT IN LIABILITY FOR WRONGFUL EXECUTION.

I certify that I have read this Debt Calculation form and to the best of my knowledge, information and belief the amount shown as owing is correct.

Creditor (Creditor must sign if writ issued by court administrator.)

Garnishor (Attorney for Creditor or other person authorized by law to issue writ.)

Address

Telephone Number

Oregon State Bar Number (if attorney)

_______________, 2__

Date of Calculation

______________________________________________________________________________ [2001 c.249 §60; 2003 c.576 §74]