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7 / 2 '7 / 94 { doc / diacloa2 _ CA ) Ow <br /> � \167 A � ENaA� <br /> INDIAN RIVER COUNTY <br /> FOOD AND REFRESHMENT _ a <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 : <br /> Meal ( circle one ) : breakfast , lunch dinner <br /> Provided by : (2cs� rot- <br /> Signature . <br /> Printed name . . ��� � <br /> Date : <br />