Form Naa-02 - Connecticut Neighborhood Assistance Act Business Application - 2015
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1Department of Revenue Services
2015
State of Connecticut
Form NAA-02
(Rev. 03/15)
2015 Connecticut Neighborhood Assistance Act Business Application
Each business fi rm applying for a tax credit under the
The business must make its contribution during its income
Neighborhood Assistance Act (NAA) Program must complete
year that begins in 2015.
and submit Form NAA-02 for each cash contribution for
Business fi rms requesting a tax credit under the NAA
which a tax credit is being requested. Form NAA-02 may be
program must be authorized to do business in Connecticut
submitted on or after September 15, 2015, but no later than
and subject to the Insurance Premiums Tax (Chapter
October 1, 2015.
207), Corporation Business Tax (Chapter 208), the Public
To electronically submit your application, email a signed
Services Companies taxes (Chapters 209, 210, 211 or 212)
copy of Form NAA-02 to NAAProgram@ct.gov.
or the Business Entity Tax (Chapter 213a). For purposes
of a business entity subject to the Business Entity Tax, the
Any Form NAA-02 that is not electronically submitted may
credit may only be used by the members or partners of the
be mailed or hand-delivered (no faxes will be accepted), to:
entity that are subject to the Corporation Business Tax.
Department of Revenue Services
Research Unit
For additional information, contact the Department of
25 Sigourney Street Ste 2
Revenue Services (DRS), Research Unit at
Hartford CT 06106-5032
860-297-5687.
Part I - Business Firm Information
Business name
CT Tax Registration Number
Business address
Number and street
PO Box
City or town
State
ZIP code
Name of contact person
Telephone number
Title
Email address of contact person
May DRS approve this application through an email to your contact person?
Yes
No
Enter income year beginning
, 2015, and ending
,
______________________________
___________________________
___________
Type of business
C Corporation
Other (specify)
______________________________ ________________________________________
Tax type against which the credit will be used
Corporation Business Tax
Insurance Premiums Tax
Public Service Companies Tax
Part II - Program Proposal Information
Organization/municipal agency
Program title
Municipality approving program
Amount of cash contribution ($250 minimum).
$
________________________________________________________
________________________________________________________________
Authorized representative’s name (print)
Authorized representative’s title
________________________________________________________
________________________________________________________________
Authorized representative’s signature (Do not use black ink)
Date
Print
Submit
Reset
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