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23 ) <br /> INDIAN RIVER COUNTY I r 1 <br /> FOOD AND REFRESHMENT EVENT <br /> DISCLOSURE FORM <br /> SECTION 104a06 ( 5 ) ( b ) ( 2 ) OF THE COUNTY CODE ` I <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 /> � l <br /> Date of subject event : l� <br /> Meal ( circle one ) : breakfast , lunch , dinner <br /> Provided by : ,,. <br /> 12 <br /> Signature : <br /> Printed name : <br /> dy <br /> Date Zf d� <br />