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INDIAN RIVER COUNTY
FOOD AND REFRESHMENT
DISCLOSURE FORM � 711
SECTION 104006 ( 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 : � L
Meal ( circle one ) : breakfast , lunch , dinner
Provided by : C fpm �f7`ofi :M1d �i a144 rr% yL
Signature : /
Printed 61aemea
Date :