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( � / 27 / 9A ( c3ac / d i. qac ]. am2 dac ) Ow <br /> t � <br /> A/or A 6rN0� <br /> INDIAN RIVER COUNTY — q <br /> FOOD AND REFRESHMENT o2 O/O v <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 : r 1 AD <br /> Meal ( circle one ) : breakfast , unch , dinner <br /> Provided by : / <br /> , • a PZ6 Signature : <br /> QN. Gid <br /> Q0 . W ; Printed name : <br /> - � <br /> ; � : : } ` <br /> OOP Date : <br /> oJ •. <br /> ��CO � • • ' • . . . •p�f1 A+a <br /> OObbbn44b bf� Ot' py d[N`"od <br />