Form Naa-01 - Connecticut Neighborhood Assistance Act (Naa) Program Proposal - 2015 Page 5
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52015 Connecticut Neighborhood Assistance Act (NAA)
Program Proposal
Instructions
Complete all items on Form
NAA-01,
2015 Connecticut Neighborhood Assistance Act (NAA) Program Proposal.
Incomplete applications will not be accepted. Direct inquiries to Department of Revenue Services (DRS),
Neighborhood Assistance Act Program, Attn: Research Unit, 25 Sigourney St Ste 2, Hartford CT 06106, or call
860-297-5687.
Part I General Information
Part III Financial Information
Enter the name of the tax exempt organization
Each program proposal must include a program budget
that includes all sources of funding and all anticipated
or municipal agency, address, Federal Employer
Identifi cation Number, and email address.
expenditures. The information provided in the budget
may be used during a post-project audit.
Program Title: Assign a unique program title to each
Sources of Revenue: The budget must include the
program for which your organization is making an
application.
requested NAA funding and any other anticipated
revenue sources.
Federal Form 990: Attach a copy of the fi rst page of
NAA Funding Requested: Indicate the total amount
your organization’s most recent federal Form 990 or
Form 990EZ. If your organization is not required to fi le
your organization is requesting for its program.
either Form 990 or Form 990EZ, attach a copy of the
This amount may not exceed the total proposed
determination letter from the Internal Revenue Service.
expenditures. Please note that the minimum NAA
funding is $250, with a maximum funding of $150,000
Part II Program Information
per organization or agency per year.
Description of Program: Describe the program,
Other Funding Sources: Provide a detailed
including information about how the program will
description(s) and the amount(s) of all funding sources.
operate, its benefi t to the community, how recipients
Proposed Program Expenditures: The budget must
will be selected, and any measures used to determine
include a detailed description and the amount of all
the program’s impact on the community.
direct operating and administrative expenditures.
Need for Program: Demonstrate a need for this
Expenditures must equal or exceed total funding.
program. For example, provide relevant statistics.
Direct Operating Expenses: Expenses include
Neighborhood Area to Be Served: Describe the
materials, equipment, wages, salaries, tuition fees,
neighborhood or municipality this program will serve.
sub-contracting services, and any other expenses
needed to administer the program.
Total Number of Recipients: Provide an estimate of
the number of recipients this program will serve.
Part IV Municipal Information
Administration of Program: Identify the name and
This part is to be completed by the municipal agency
address of every person or organization involved in
overseeing implementation of the program.
the implementation and administration of this program.
Municipal Liaison: The municipality must designate
Use additional sheets if necessary.
an individual to serve as a liaison with DRS for all
Timetable: Indicate the starting and completion dates
NAA matters.
of the program. The program completion date must not
be more than two years from the program start date.
Post-Project Review: Any program receiving $25,000 or
more in NAA funding is required to provide a post-project
review, prepared by a certified public accounting
fi rm, to the municipality overseeing the program. This
review must be submitted to the municipality no later
than three months after the program completion date.
Page 5 of 5
Form NAA-01 (Rev. 02/15)
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