Vaccination Exemption Affidavit

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Your Information
Full legal name
Date of birth (MM-DD-YYYY)
Complete Address
Place of birth
Country of citizenship
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Affidavit Details
Reason for Seeking 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
Disease Name

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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.

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

Document progress

0 of 7 fields complete

Saved on this device only.

1
Your Information
Full legal name
Date of birth (MM-DD-YYYY)
Complete Address
Place of birth
Country of citizenship
2
Affidavit Details
Reason for Seeking 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
Disease Name

Live preview

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.