Lost At Sea Monument Eligibility Application
Name of Person Lost:__________________________________________________________
Name as you would like it to appear on monument: ___________________________________________________________________________
Where was person born?
City_____________________County_____________________State_____________________
Date of Birth:_____________________ Date of Loss:_________________________________
Where did person reside at time of loss?___________________________________________
Location of Loss:_______________________________________________________________
Details of Loss: Please include specifics such as vessel the person was lost from, recreational activity person was involved in when lost, etc. Please specify location of loss including county. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Do you have any type of written proof of the loss. This should be a US Coast Guard report, newspaper article, etc. ___Yes or ___No Please explain and attach or mail a copy. ______________________________________________________________________________ ______________________________________________________________________________
Name of person preparing application:____________________________________________
Address:______________________________________________________________________
Phone #’s:_____________________________________________________________________
Relationship to person lost:______________________________________________________
Was body recovered? ___Yes or ___No
Does person lost have immediate family in South Carolina? ___Yes or ___No
If yes, please specify county.______________________________________________________
If person was lost from a vessel, was the vessel docked in South Carolina? ___Yes or ___No
If so, name of vessel and location including county it was docked. ____________________________________________________________________________________________________________________________________________________________
Signature____________________________ Date_____________________________________
