Affidavits
Sworn Declaration of Vaccination Exemption
A sworn affidavit stating a personal vaccination exemption position. Fill it in online, download a ready-to-sign PDF, and notarize in Ontario. The body requesting it decides whether to accept it; this is not medical or legal advice.
Pay only when you notarize
Word files are editable. Review any changes carefully before signing or uploading.
Also known as
- Vaccination Exemption Affidavit
- Sworn Vaccine Exemption Statement
- Notarized Vaccine Exemption
SWORN DECLARATION — COVID-19 VACCINATION EXEMPTION
I, ______, of ______, DO SOLEMNLY DECLARE AND STATE:
I was born on ______ in ______.
I am a citizen of ______.
I hereby request an exemption from receiving the COVID-19 vaccine, or any related vaccines, boosters or other shots related to COVID-19 and any of its variants.
The COVID-19 vaccine ______.
The purpose of this declaration is to request a formal exemption from any mandatory or non-mandatory vaccination requirements, whether by law, health directive, provincial or state mandate, or resulting from an employer’s rules, policies or orders.
I make this declaration in support of my request for a COVID-19 vaccine exemption, and for no improper purpose.
AND I make this solemn declaration conscientiously believing it to be true, and knowing that it is of the same force and effect as if made under oath and by virtue of the Canada Evidence Act.
Signed and sworn (or affirmed/declared) before me by videoconference in Ottawa, Ontario, while the Affiant(s)/Declarant(s) were located in ______________________, on ______________________, pursuant to O. Reg. 431/20, and Electronic Commerce Act, 2000.
______________________________ | ______________________________ |
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- Scope
- General template, not legal advice
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Sworn Declaration of Vaccination Exemption
A compact preview of this template
01Your Information
Full legal name
Complete residential address
Date of birth
SWORN DECLARATION — COVID-19 VACCINATION EXEMPTION
I, ______, of ______, DO SOLEMNLY DECLARE AND STATE:
I was born on ______ in ______.
I am a citizen of ______.
I hereby request an exemption from receiving the COVID-19 vaccine, or any related vaccines, boosters or other shots related to COVID-19 and any of its variants.
The COVID-19 vaccine ______.
The purpose of this declaration is to request a formal exemption from any mandatory or non-mandatory vaccination requirements, whether by law, health directive, provincial or state mandate, or resulting from an employer’s rules, policies or orders.
I make this declaration in support of my request for a COVID-19 vaccine exemption, and for no improper purpose.
AND I make this solemn declaration conscientiously believing it to be true, and knowing that it is of the same force and effect as if made under oath and by virtue of the Canada Evidence Act.
Signed and sworn (or affirmed/declared) before me by videoconference in Ottawa, Ontario, while the Affiant(s)/Declarant(s) were located in ______________________, on ______________________, pursuant to O. Reg. 431/20, and Electronic Commerce Act, 2000.
______________________________ | ______________________________ |
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Overview
About this document
- 01
What is a vaccine exemption affidavit?
It is a sworn statement in which a person sets out their stated exemption position.
A notary administers the oath and witnesses the signature; the notary does not assess the exemption or provide medical or legal advice.
- 02
Good to know
The organization, employer, or authority requesting it decides whether it accepts an exemption and on what terms. Requirements vary, so confirm what the requesting body needs. This service is the notarization only and is not medical or legal advice.
- 03
How to notarize a vaccine exemption affidavit in Ontario
After you fill in your vaccine exemption affidavit and download the PDF, do not sign it in advance. A sworn document must be signed in front of a notary public or commissioner for taking affidavits, who administers your oath or solemn affirmation first.
Minute Notary commissions your vaccine exemption affidavit online by secure video, under Ontario's remote commissioning rules (O. Reg. 431/20), or in person in Ottawa. Bring valid government-issued photo identification.
Good to know
Before you fill it in.
Short notes from our notary on this template. Worth a minute before you start.
- 01
Reviewed for use in Ontario by a notary public and commissioner for taking affidavits.
- 02
Fill it in online for free and download a ready-to-sign PDF — no account required.
- 03
Sign in front of the notary, who administers your oath or witnesses your signature and applies the seal.
- 04
Notarize online by video across Ontario, or in person in Ottawa.
Frequently asked
Questions about the Sworn Declaration of Vaccination Exemption
- Does notarizing this make my exemption valid?
- No. Notarizing confirms the statement was sworn before a notary. The body requesting it decides whether it accepts an exemption and on what terms.
- Is this medical or legal advice?
- No. The notary administers the oath and witnesses the signature only; it is not medical or legal advice.
- Can I notarize it online in Ontario?
- Yes. You can complete it online by video under Ontario’s remote commissioning rules, or in person in Ottawa with Minute Notary.
- Will my employer or school accept it?
- That is for the requesting organization to decide. Confirm their requirements before relying on it.
Keep exploring
Related templates
Other documents for identity & personal status.
- 01Vaccination Exemption Affidavit
A sworn statement of a general vaccination exemption position, notarized. Fill it in online, download a ready-to-sign PDF, and notarize in Ontario. The body requesting it decides whether to accept it; this is not medical or legal advice.
Fill it out - 02General Affidavit (Ontario)
A free, general-purpose affidavit for Ontario: set out your facts as numbered paragraphs and swear or affirm them before a notary public or commissioner for taking affidavits. Fill it in online, download a ready-to-sign PDF, and notarize online or in Ottawa.
Fill it out - 03Statement of Conscience or Religious Belief (Immunization of School Pupils Act)
A sworn statement by a parent or guardian that Ontario’s Immunization of School Pupils Act requirements conflict with their sincerely held religious belief or conscience — used to request a non-medical school immunization exemption.
Fill it out - 04Vaccination Status Affidavit
A sworn affidavit attesting to your vaccination status. Fill it in online, download a ready-to-sign PDF, and notarize in Ontario. The body requesting it decides whether to accept it; this is not medical advice.
Fill it out
Ready to sign?
Ready to create your Sworn Declaration of Vaccination Exemption?
Fill it in online, then download a ready-to-sign PDF or an editable Word copy. This document must be signed in person. Not sure what the appointment involves? Read about the Statutory Declarations service first.