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Vaccination 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.
Pay only when you notarize
Word files are editable. Review any changes carefully before signing or uploading.
Also known as
- General Vaccination Exemption Affidavit
- Sworn Vaccination Exemption
- Notarized Exemption Statement
Vaccine Exemption Affidavit
I, ______, of ______, DO SOLEMNLY SWEAR (or AFFIRM) 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 unlawful or improper purpose.
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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- General template, not legal advice
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Vaccination Exemption Affidavit
A compact preview of this template
01Affidavit Details
Reason for Seeking Vaccine Exemption
Full legal name
Date of birth
Vaccine Exemption Affidavit
I, ______, of ______, DO SOLEMNLY SWEAR (or AFFIRM) 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 unlawful or improper purpose.
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 this document?
It is a sworn statement of a general vaccination exemption position, witnessed by a notary public or commissioner.
The notary administers the oath and witnesses the signature; it 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. Confirm their requirements. This service is the notarization only and is not medical or legal advice.
- 03
How to notarize a general vaccination exemption statement in Ontario
After you fill in your general vaccination exemption statement 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 general vaccination exemption statement 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 Vaccination Exemption Affidavit
- Does notarizing make my exemption valid?
- No. It confirms the statement was sworn before a notary. The requesting body 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.
- 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 it be accepted?
- 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.
- 01Sworn 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.
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 - 03Primary Residence Sworn Statement
A sworn statement confirming that a property is your principal (primary) residence — used for lenders, insurers, and tax or benefit purposes. Fill it in online, download a ready-to-sign PDF, and notarize in Ontario.
Fill it out - 04Supporting Affidavit for a Small Claims Motion (Form 15A)
Form 15A carries a Small Claims Court motion and the affidavit that supports it on one document. Only the affidavit half is sworn — prepare that wording here, then swear it before a notary.
Fill it out
Ready to sign?
Ready to create your Vaccination Exemption Affidavit?
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.