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

Please check the appropriate description of your program:

______ 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; or

______ Other: Specify ____________________________________________________ .

Part II — Program Information

Description of program: _____________________________________________________________

________________________________________________________________________________

Need for program: _________________________________________________________________

________________________________________________________________________________

Neighborhood area to be served: _____________________________________________________

________________________________________________________________________________

Total number of recipients: __________________________________________________________

Administration of Program:

Identify every person or organization involved in the implementation and administration of the program.

Use additional sheets if necessary.

1. Name: _______________________________________________________________________

Address: _____________________________________________________________________

_________________________________________________________________________

Duties and responsibilities: _______________________________________________________

_________________________________________________________________________

Connecticut Tax Registration Number or Social Security Number (SSN): ____________________

2. Name: _______________________________________________________________________

Address: _____________________________________________________________________

_________________________________________________________________________

Duties and responsibilities: _______________________________________________________

_________________________________________________________________________

Connecticut Tax Registration Number or SSN: ________________________________________

Form NAA-01 (Rev. 02/09)

Page 2 of 5

Form Naa-01 - Connecticut Neighborhood Assistance Act (Naa) Program Proposal - 2009 Page 2