Affidavits
Sworn Declaration of Vaccination Exemption
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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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