Form Naa-02 - Connecticut Neighborhood Assistance Act Business Application - 2002
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1DEPARTMENT OF REVENUE SERVICES
STATE OF CONNECTICUT
(Rev. 2/02)
Form NAA-02
2002 Connecticut Neighborhood Assistance Act
Business Application
Each business firm requesting a tax credit under the Neighborhood Assistance Act
Program must complete and submit this form. A separate Form NAA-02, 2002 Connecticut
Neighborhood Assistance Act Business Application, is required for each cash contribution
for which a tax credit is being requested. Form NAA-02 must be mailed or hand-delivered
to the Department of Revenue Services, 25 Sigourney Street, Hartford CT 06106,
Attn: Research Unit, on or after September 15, 2002, but no later than October 1, 2002.
A faxed Form NAA-02 will not be accepted. For additional information, contact the
Research Unit at: 860-297-5687.
Part I: Business Firm Information
Business Firm Name:______________________________________________________
Address: _______________________________________________________________
Federal Employer Identification Number: ______________________________________
Connecticut Tax Registration Number: ________________________________________
Income Year Ending: ______________________________________________________
Name of Contact Person: __________________________________________________
Title: __________________________________________________________________
(
)
Telephone Number: _______________________________________________________
Part II: Program Proposal Information
Organization/Municipal Agency: _____________________________________________
Program Title: ___________________________________________________________
Municipality Approving Program: ____________________________________________
Amount of Cash Contribution: $_____________
% Credit:_____________
($250 Minimum)
(40% or 60%)
Has this contribution been made?
Yes
No
____/____/____
If yes, date made:
____/____/____
If no, date to be made:
(
)
NOTE: Contribution must be made during the income year of the business beginning during 2002.
____________________________
_________________________________
Signature of Authorized Representative
Name and Title of Authorized Representative
of Business Firm
of Business Firm
(Do Not Use Black Ink)
(Please Print)
______________________
Date
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