The notice of lien required under ORS 87.613 shall be a statement in writing verified by the oath of the person or an officer of the governmental unit asserting the lien claim and must contain:
(1) A true statement of demand, after deducting all credits and offsets;
(2) The name of the individual who received ambulance services;
(3) An itemized statement of the ambulance services provided;
(4) A statement that the amount claimed is a true and bona fide existing debt as of the date of the filing of the notice of lien; and
(5) The date on which payment for the ambulance services is due.