Form Naa-02 - Connecticut Neighborhood Assistance Act Business Application - 2012
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2012
Department of Revenue Services
State of Connecticut
Form NAA-02
(Rev. 08/12)
2012 Connecticut Neighborhood Assistance Act Business Application
Each business firm requesting a tax credit under the
Legislation enacted in 2011 expanded the eligibility for the
Neighborhood Assistance Act (NAA) Program must
NAA program to include any business entity authorized to
do business in Connecticut and subject to the Business Entity
complete and submit Form NAA-02 for each cash
Tax. However, for purposes of a business entity subject to
contribution for which a tax credit is being requested. Form
the Business Entity Tax, the credit may only be used by
NAA-02 must be mailed or hand-delivered (no faxes will be
accepted) on or after September 15, 2012, but no later than
the members or partners of the entity that are subject to the
October 1, 2012, to:
Corporation Business Tax.
Department of Revenue Services
The business must make its contribution during its
income year that begins in 2012.
Research Unit
25 Sigourney St Ste 2
For additional information, contact the Department of
Revenue Services (DRS), Research Unit at 860-297-5687.
Hartford CT 06106-5032
Part I - Business Firm Information
Business name
CT Tax Registration Number
Business address
Number and street
PO Box
City or town
State
ZIP code
Name of contact person
Telephone number
Title
Email address of contact person
Enter income year beginning
, 2012, and ending
,
______________________________
___________________________
___________
Type of business
C Corporation
Other (specify)
______________________________ ________________________________________
Tax type against which the credit will be used
Corporation Business Tax
Insurance Premiums Tax
Public Service Companies Tax
Part II - Program Proposal Information
Organization/municipal agency
Program title
Municipality approving program
Amount of cash contribution ($250 minimum).
$
________________________________________________________
________________________________________________________________
Authorized representative’s name (print)
Authorized representative’s title
________________________________________________________
________________________________________________________________
Authorized representative’s signature (Do not use black ink)
Date
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