Sworn Declaration of Vaccination Exemption

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Your Information
Full legal name
Complete residential address
Date of birth
Place of birth
Country of citizenship
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Exemption Details
Basis for requesting vaccine exemption
conflicts with my sincerely held convictions based on my religion or conscienceis not necessary due to a medical exemptionconflicts with my sincerely held convictions based on my religion or conscience and is not necessary due to a medical 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 Affidavit 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 swear this Affidavit in support of my request for a COVID-19 vaccine exemption, and for no other unlawful or improper purpose.

Fill in the fields on the left. Your document updates live on the right.

Document progress

0 of 6 fields complete

Saved on this device only.

1
Your Information
Full legal name
Complete residential address
Date of birth
Place of birth
Country of citizenship
2
Exemption Details
Basis for requesting vaccine exemption
conflicts with my sincerely held convictions based on my religion or conscienceis not necessary due to a medical exemptionconflicts with my sincerely held convictions based on my religion or conscience and is not necessary due to a medical exemption

Live preview

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 Affidavit 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 swear this Affidavit in support of my request for a COVID-19 vaccine exemption, and for no other unlawful or improper purpose.