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A sworn declaration used by Ontario residents who need to formally attest their exemption from a vaccination requirement, whether for employment, school admission, or other institutional obligations.
Also known as
Vaccine Exemption Affidavit
I, ______ of ______, DO SOLEMNLY SWEAR AND DECLARE:
I was born on ______ in ______.
I am a citizen of ______.
I hereby request an exemption from receiving the ______ vaccine, or any related vaccines, boosters or other shots related to ______ and any of its variants.
The ______ 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 ______ vaccine exemption, and for no other unlawful or improper purpose.
How it works
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A vaccination exemption affidavit is a sworn statement in which you declare under oath that you are seeking exemption from a mandatory vaccination requirement. It is used when an employer, school, or other organisation has a vaccination policy and permits (or requires) a formal sworn declaration from individuals who do not comply.
The affidavit does not grant you an exemption on its own. It is your legal declaration of the grounds on which you are requesting one. Whether the exemption is accepted depends entirely on the requesting organisation's accommodation process.
Ontario's Human Rights Code (R.S.O. 1990, c. H.19) protects individuals from discrimination on the basis of creed, which includes sincerely held religious beliefs and beliefs of conscience. This affidavit allows you to declare one or more of the following grounds.
The form collects the personal details and exemption particulars the notary needs to complete your sworn statement.
You will need valid government-issued photo identification so the notary can verify your identity before administering the oath. Accepted forms of ID include the following.
The notary's role is strictly limited: they verify your identity, administer the oath or affirmation, watch you sign, and apply the notarial seal and jurat. The notary does not assess the sincerity of your beliefs, does not provide legal or medical advice, and cannot guarantee acceptance of your exemption.
This affidavit can be commissioned virtually under Ontario Regulation 431/20, provided both you and the notary are physically located in Ontario during the video call. The fee is a flat $19.90 per notarial stamp.
The notary does not endorse your exemption claim. Whether your employer or institution accepts the affidavit depends on their policy and their duty-to-accommodate analysis under the Human Rights Code. If you need advice on whether your claim is likely to succeed, consult a lawyer or contact the Ontario Human Rights Tribunal.
Swearing a false affidavit is perjury under section 131 of the Criminal Code of Canada, an indictable offence carrying up to 14 years' imprisonment. You are personally responsible for the truth of every statement in the document.
Frequently asked
Fill it in online, download a ready-to-sign PDF, then bring it in and we will notarize it, in person across Ottawa or online.