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;

______ 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: ____________________

2. Name: _________________________________________________________________

Address: ________________________________________________________________

____________________________________________________________________

Duties and Responsibilities: _________________________________________________

____________________________________________________________________

Connecticut Tax Registration Number or Social Security Number _____________________

Form NAA-01 (Rev. 2/05)

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Form Naa-01 - Connecticut Neighborhood Assistance Act (Naa) Program Proposal - 2005 Page 2