Form Naa-01 - Connecticut Neighborhood Assistance Act (Naa) Program Proposal - 2017 Page 5
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52017 Connecticut Neighborhood Assistance Act (NAA)
Program Proposal
Instructions
Complete all items on Form
NAA-01,
2017 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, 450 Columbus Blvd Ste 1, Hartford CT 06103-1837,
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.
Plan to implement the program: Describe how
the program will operate. Identify other persons or
Part IV Municipal Information
organizations involved in the administration of the
program.
This part is to be completed by the municipal agency
overseeing implementation of the program.
Timetable: Indicate the starting and completion dates
Municipal Liaison: The municipality must designate
of the program. The program completion date must not
be more than two years from the program start date.
an individual to serve as a liaison with DRS for all
NAA matters.
Post-Project Review: Any program receiving $25,000
or more in NAA funding is required to provide a
post-project review, prepared by a certifi ed 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.
Form NAA-01 (Rev. 03/17)
Page 5 of 5
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