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Department of Revenue Services
State of Connecticut
Form NAA-02
(Rev. 02/09)
2009 Connecticut Neighborhood Assistance Act (NAA)
Business Application
Each business fi rm requesting a tax credit under the Neighborhood Assistance Act (NAA) Program
must complete and submit this form for each cash contribution for which a tax credit is being requested.
Form NAA-02 must be mailed or hand-delivered to:
Department of Revenue Services
25 Sigourney St Ste 2
Hartford CT 06106
Attn: Research Unit
on or after September 15, 2009, but no later than October 1, 2009. A faxed Form NAA-02 will not be
accepted.
Subchapter S corporations, limited liability companies, limited liability partnerships, and limited
partnerships are not eligible for the credit. For additional information, contact the Research Unit at
860-297-5687.
Part I: Business Firm Information
Business fi rm name: _______________________________________________________________
Address: ________________________________________________________________________
Federal Employer Identifi cation Number: _______________________________________________
Connecticut Tax Registration Number: _________________________________________________
Income year ending: _______________________________________________________________
Name of contact person: ____________________________________________________________
Title: ___________________________________________________________________________
Email address of contact person: _____________________________________________________
(
)
__________________________________________________________
Telephone number:
Part II: Program Proposal Information
Organization/municipal agency: ______________________________________________________
Program title: _____________________________________________________________________
Municipality approving program: ______________________________________________________
Amount of cash contribution: $ _______________________________________________________
($250 minimum)
Has this contribution been made?
Yes
No
If Yes, date made: ______________
If No, date to be made: ______________
Note: The business must make its contribution during its 2009 income year.
__________________________
______________________________
Signature of authorized representative
Name and title of authorized representative
of business fi rm
of business fi rm
(Do not use black ink)
(Please print)
_____________________________________________
Date
1
