Form Naa-02 - Neighborhood Assistance Act Business Application

Form Naa-02 - Neighborhood Assistance Act Business Application - 1999

1999 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 is required for

each cash contribution for which credit is being requested. All forms NAA-02 must be

mailed or hand-delivered to the Department of Revenue Services, 25 Sigourney Street,

Hartford, Connecticut 06106, Attn: Research Unit, on or after September 15, 1999,

but no later than October 1, 1999. Telecopied applications will not be accepted.

PART I: BUSINESS FIRM INFORMATION

Business firm name: ___________________________________________________

Address: ____________________________________________________________

Federal Employer Identification Number: __________________________________

Connecticut Tax Registration Number: ____________________________________

Tax year end:_________________________________________________________

Contact person: _______________________________________________________

Title: __________________________________________________________

Phone number: __________________________________________________

PART II: PROGRAM PROPOSAL INFORMATION

Organization/Municipal agency: _________________________________________

Program title: ________________________________________________________

Municipality approving program:_________________________________________

Amount of cash contribution: $ ______________

% Credit:______________

($250 minimum)

Has this contribution been made? If yes, date made:__________________________

If no, date to be made: _____________________

(Note: Contribution must be made in business’ income year beginning on or after

January 1, 1999.)

__________________________

________________________________

Signature of Authorized Representative

Name and Title of Authorized Representative

(Do Not Use Black Ink)

(Please Print)

______________________________

Date

NAA-02 (Rev. 1/99)

Form Naa-02 - Neighborhood Assistance Act Business Application - 1999