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INDIAN RIVER COUNTY <br />FOOD AND REFRESHMENT <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 />breakfast, lunch, dinner <br />Meal (circle one) <br />W <br />Provided by: i M <br />C <br />Signature: <br />Printed name: <br />name: <br />Date:%��r0 <br />