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INDIAN RIVER COUNTY X67
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 : 1 /
Meal ( circle one ) : breakfast , lunch , inner
Provided by : S'J' Q '42 q'
Signature :
Printed name : �e ��� ry ��
Date :