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90 ) 7 - j 2 <br /> INDIAN RIVER COUNTY 10 a ` I65 <br /> FOOD AND REFRESHMENT NOT AGRDASSEM) <br /> DISCLOSURE FORM <br /> SECTION 104 . 06 ( 5 ) ( b ) ( 2 ) OF THE COUNTY CODE <br /> I consumed food and / or refreshments at a single sitting or event , <br /> the cost of which may have exceeded the per diem allowance under <br /> Chapter 112 , F . S . , as follows : <br /> Date of subject event : , 59i j- _ 27 , Zbl Z <br /> Meal ( circle one ) : breakfast , unch , dinner <br /> Provided by : �0� 5 � � L' L� � y �V �c `'I Cal <br /> � r <br /> Signatures <br /> Zr.� <br /> Printed name : <br /> Date : <br />