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INDIAN RIVER COUNTY 10 a ` I65
FOOD AND REFRESHMENT NOT AGRDASSEM)
DISCLOSURE FORM
SECTION 104 . 06 ( 5 ) ( b ) ( 2 ) OF THE COUNTY CODE
I consumed food and / or refreshments at a single sitting or event ,
the cost of which may have exceeded the per diem allowance under
Chapter 112 , F . S . , as follows :
Date of subject event : , 59i j- _ 27 , Zbl Z
Meal ( circle one ) : breakfast , unch , dinner
Provided by : �0� 5 � � L' L� � y �V �c `'I Cal
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Signatures
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Printed name :
Date :