Form Naa-01 - Connecticut Neighborhood Assistance Act (Naa) Program Proposal - 2017
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Department of Revenue Services
State of Connecticut
(Rev. 03/17)
Municipality:
_______________________________
Form NAA-01
2017 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 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): $
__________________________
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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