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INDIAN RIVER COUNTY I r 1
FOOD AND REFRESHMENT EVENT
DISCLOSURE FORM
SECTION 104a06 ( 5 ) ( b ) ( 2 ) OF THE COUNTY CODE ` I
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 :
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Date of subject event : l�
Meal ( circle one ) : breakfast , lunch , dinner
Provided by : ,,.
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Signature :
Printed name :
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Date Zf d�