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INDIAN RIVER COUNTY v ` e:?
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 : ;7
e
� r
Signature : � 6c
Printed name :
Date :