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eJOt AGENAA �— <br /> INDIAN RIVER COUNTY <br /> FOOD AND REFRESHMENT � Q • � 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 : e,C' z- <br /> Meal ( circle one ) : breakfast , lunch , inner <br /> Provided by : /V 1 <br /> c <br /> Signature <br /> -- - - - --Pr-inted--name-. �600' 4 <br /> Date * 3 Z.O/ 2 <br /> �l <br />