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

Form Naa-01 - Connecticut Neighborhood Assistance Act (Naa) Program Proposal - 2003

DEPARTMENT OF REVENUE SERVICES

STATE OF CONNECTICUT

(Rev. 3/03)

Municipality: ____________________

Form NAA-01

2003 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 Identification Number: _____________________________________

Program Title: __________________________________________________________

Name of Contact Person: _________________________________________________

(

)

Telephone Number: ______________________________________________________

Total NAA Funding Requested

$ ______________________

($250 Minimum, $150,000 Maximum):

Credit Percentage for Which Your Organization is Applying (Check One):

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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Form Naa-01 - Connecticut Neighborhood Assistance Act (Naa) Program Proposal - 2003