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022
INDIAN RIVER COUNTY
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 :
Meal ( circle one ) :
breakfast , lunch , dinner
Provided by . �S a _
Signature : e'-"'
Printed name *
e��� �d-� C
Date : /LG Lj L� , Zb / /