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o ! v 96 <br /> 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 /> Meal ( circle ane ) : breakfast , lunch , dinner <br /> Provided by : � i1 (ff <br /> Signature : L <br /> Printed name : <br /> Date . <br />