This is as close to compliance with my interpretation of the law I sited above.
For more information on religious exemptions www.forunitedsolutions.org
AFFIDAVIT OF VACCINE EXEMPTION ON RELIGIOUS GROUNDS FOR CITY EMPLOYEES
Governing Authority Name (entity issuing mandate): _______________________________
RE: Religious Exemption from Immunization Requirements
I, (Legal Name), ______________________________ the undersigned, do hereby swear and affirm that I
am a member of a recognized religious organization, and that the immunizations required by (Governing
Authority Name) ______________________________ are contrary to my religious tenets and practices.
On this basis, as the above referenced immunization requirements violate my right to freely exercise my
religion as guaranteed by the First Amendment of the Constitution of The United States of America, I am
asserting my rights to an exemption from (Governing Authority Name)
______________________________ immunization requirements.
I qualify for this exemption based on the following:
1) First Amendment of the United States Constitution
2) Title VII of the Civil Rights Act (42 U.S. Code § 2000e) prohibits discrimination against a
sincerely held religious belief, practice, or observance. As enforced by the U.S. Equal
Employment Opportunity Commission, Title VII requires employers to reasonably accommodate
an employee's sincerely held religious belief, practice, or observance. For religious
accommodation request, according to the EEOC's COVID-19 guidance, employers should
ordinarily assume that an employee's request for religious accommodation is based on a sincerely
held religious belief, practice, or observance.
EEOC guidance also reminds employers that the ADA prohibits employers from both disclosing that an
employee is receiving a reasonable accommodation and retaliating against an employee for requesting an
Failure to uphold 42 U.S. Code § 2000e and any attempt to coerce an individual to get the Covid-19
vaccine is a violation of federal law and may be met with legal action.
Thank you in advance,
--------------------------Notarial Certificate – To be filled out by a notary public--------------------
State of ______________
County of ____________
On __________ before me, ___________(here insert name and title of the officer), personally appeared
__________________, who proved to me on the basis of satisfactory evidence to be the person(s) whose
name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the
same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the
person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of ______________ that the
foregoing paragraph is true and correct.
WITNESS my hand and official seal.