THE CHURCH OF SPIRITUAL AWAKENING, Inc.
909 B East Oak Street
Kissimmee, FL 34744
HEALING AFFIDAVIT

This form may be completed by those who have received healing through a Spiritualist Healer, whether the healing was physical, mental or spiritual. This may refer to a single healing, several healing's or absentee healing. Thank you.

Name of Spiritual Healer: ___________________________________________________

Name of person who received healing: ________________________________________

Address: _________________________________________________________________

Email Address: ____________________________________________________________

Date(s) of healing: _________________________________________________________

Specific healing condition treated: ____________________________________________

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Result(s) of the healing(s): __________________________________________________

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Signature of Patient: _________________________________________ Date: _________

Subscribed and sworn before me this: __________ day of ______________ , 2________

My commission expires: ___________________________________ SEAL

Notary Public: ___________________________________________