Form Naa-01 - Connecticut Neighborhood Assistance Act (Naa) Program Proposal - 2007
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Department of Revenue Services
State of Connecticut
(Rev. 02/07)
Municipality: ____________________
Form NAA-01
2007 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 Identification Number: __________________________________________
Program Title: ______________________________________________________________
Name of Contact Person: ______________________________________________________
Telephone Number: __________________________________________________________
(
)
Total NAA Funding Requested
$ _____________________
($250 Minimum, $150,000 Maximum):
Is your organization required to file federal Form 990 or 990EZ, Return of Organization
Exempt from Income Tax?
Yes
No
If Yes, attach a copy of the first 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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