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INDIAN RIVER COUNTYU/D
FOOD AND REFRESHMENT
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 : [ z d 0
Meal ( circle one ) : breakfast , lunch , dinner
Provided by * � M
C
0?4L
Printed name : T& 4G/J 0 c 144cl
Date :