Form Naa-02 - Connecticut Neighborhood Assistance Act Business Application - 2001
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1FORM NAA-02
2001 Connecticut 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 a tax credit is being requested.
Form NAA-02 must be mailed or hand-delivered to the Department of Revenue
Services, 25 Sigourney Street, Hartford CT 06106, Attn: Research Unit,
on or after September 15, 2001, but no later than October 1, 2001. A faxed
Form NAA-02 will not be accepted. For additional information, contact the
Research Unit at 860-297-5687.
PART I: BUSINESS FIRM INFORMATION
Business firm name: _______________________________________________
Address: ________________________________________________________
Federal Employer Identification Number: _______________________________
Connecticut Tax Registration Number: _________________________________
Income year ending: _______________________________________________
Contact person: __________________________________________________
Title: _______________________________________________________
Telephone number: ___________________________________________
PART II: PROGRAM PROPOSAL INFORMATION
Organization/Municipal agency: ______________________________________
Program title: _____________________________________________________
Municipality approving program: ______________________________________
Amount of cash contribution: $_____________
% Credit:_____________
($250 minimum)
(40% or 60%)
Has this contribution been made?
If yes, date made:__________________________
If no, date to be made: ______________________
(NOTE:
)
Contribution must be made during the income year of the business beginning during 2001.
_________________________
______________________________
Signature of Authorized Representative
Name and Title of Authorized Representative
of Business Firm
of Business Firm
(Do Not Use Black Ink)
(Please Print)
___________________
Date
NAA-02 (Rev. 2/01)
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