Form Naa-01 - Connecticut Neighborhood Assistance Act (Naa) Program Proposal - 2011
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Department of Revenue Services
State of Connecticut
(Rev. 03/11)
Municipality: __________________________
Form NAA-01
2011 Connecticut Neighborhood Assistance Act (NAA)
Program Proposal
Complete this form in blue or black ink only.
This form must be completed and submitted to your municipality for approval. All items must be completed
with as much detail as possible. If additional space is needed, attach additional sheets. Please type or
print clearly. See attached instructions before completing. Do not submit this form directly to the
Department of Revenue Services.
Part I — General Information
Name of tax exempt organization/municipal agency: ______________________________________
________________________________________________________________________________
Address: ________________________________________________________________________
________________________________________________________________________________
Federal Employer Identifi cation Number: _______________________________________________
Program title: _____________________________________________________________________
Name of contact person: ____________________________________________________________
(
)
Telephone number: ________________________________________________________________
Email address: ___________________________________________________________________
Total NAA funding requested ($250 minimum, $150,000 maximum): $ _______________________
Credit percentage for which your organization is applying:
____________60%
______________100%
(Energy conservation programs only)
Is your organization required to fi le federal Form 990 or 990EZ, Return of Organization Exempt
from Income Tax?
Yes
No
If Yes, attach a copy of the fi rst page of your most recent return.
If No, attach a copy of your determination letter from the U.S. Treasury Department, Internal
Revenue Service.
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