Form Naa-01 - Connecticut Neighborhood Assistance Act (Naa) Program Proposal

Form Naa-01 - Connecticut Neighborhood Assistance Act (Naa) Program Proposal - 2001

Municipality: ____________________

FORM NAA-01

2001 Connecticut Neighborhood Assistance Act (NAA)

Program Proposal

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 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: __________________________________________________________

Contact Person: _________________________________________________________

(

)

Telephone Number: _____________________

Total NAA Funding Requested ($150,000 Maximum): $ _________________________

Credit Percentage for which your Organization is Applying:

_____ 60%

_____ 40%

If 60% Program, Check the Appropriate Description:

_____ Job training/education for unemployed persons aged 50 or over;

_____ Job training/education for disabled persons;

_____ Program serving low-income persons;

_____ Energy conservation;

_____ Child care services.

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NAA-01 (Rev. 2/01)

Form Naa-01 - Connecticut Neighborhood Assistance Act (Naa) Program Proposal - 2001