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FOOD AND REFRESHMENT o2 O/O v
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 : r 1 AD
Meal ( circle one ) : breakfast , unch , dinner
Provided by : /
, • a PZ6 Signature :
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Q0 . W ; Printed name :
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OOP Date :
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