Department of Revenue Services             Print Form               Reset Form
State of Connecticut
(Rev. 02/22)

Municipality:  _______________________________

                                           Form NAA-01

                    2022 Connecticut Neighborhood Assistance Act (NAA)
                                           Program Proposal

This form must be completed and submitted to your municipality for approval. All items must be completed 
with as much detail as possible. If additional space is needed, attach additional sheets. Please type or 
print clearly. See attached instructions before completing.         Do not submit this form directly to the 
Department of Revenue Services.

Part I — General Information

Name of tax exempt organization/municipal agency:  ____________________________________________

__________________________________________________________________________________________

Address:  _________________________________________________________________________________

__________________________________________________________________________________________

Federal Employer Identification Number:  ______________________________________________________

Program title:  _____________________________________________________________________________  

Name of contact person:   ___________________________________________________________________  

Telephone number: ________________________________________________________________________                                                – –

Email address:  ____________________________________________________________________________

Total NAA funding requested ($250 minimum, $150,000 maximum):  $     __________________________

 Is your organization required to file federal Form 990 or 990EZ, Return of Organization Exempt 
 from Income Tax?

                   Yes         No

 If Yes, attach a copy of the first page of your most recent return.
 If No, attach a copy of your determination letter from the U.S. Treasury Department, Internal 
 Revenue Service.

                               Visit us at portal.ct.gov/DRS for more information.

Part II — Program Information

Check the appropriate description of your program:

100% credit percentage
  ______  Energy conservation; or
  ______  Comprehensive college access loan forgiveness (see Conn. Gen. Stat. § 12-635(3)).

60% credit percentage
  ______  Job training/education for unemployed persons aged 50 or over;
  ______  Job training/education for persons with physical disabilities;
  ______  Program serving low-income persons;
  ______  Child care services;
  ______  Establishment of a child day care facility;
  ______  Open space acquisition fund; or
  ______  Other (specify):  _________________________________________________________________

Description of program:   ___________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Need for program:  ________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Neighborhood area to be served:  ___________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Plan to implement the program:   ____________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________
Form NAA-01 (Rev. 02/22)                                                                   Page 2 of 5
                           Visit us at portal.ct.gov/DRS for more information.

Timetable:

  Program start date:  __________________________________

  Program completion date:  ____________________________

  The program completion date must not be more than two years from the program start date. A certified 
  post-project audit is due to the municipality overseeing implementation no later than three months 
  after program completion date for all projects receiving $25,000 or more in NAA funding. 

Part III — Financial Information

Program Budget:
Complete in full. Expenditures must equal or exceed total funding.

Sources of Revenue:

  NAA funds requested                                              ______________________

  Other funding sources - itemized sources:
  a)   _______________________________________________             ______________________
  b)   _______________________________________________             ______________________
  c)  ________________________________________________             ______________________
  d)   _______________________________________________             ______________________

Total Funding:                                                     ______________________

Proposed Program Expenditures:

  Direct operating expenses - itemized description:
  a)   _______________________________________________             ______________________
  b)   _______________________________________________             ______________________
  c)  ________________________________________________             ______________________
  d)   _______________________________________________             ______________________

  Administrative expenses - itemized description:
  a)   _______________________________________________             ______________________
  b)   _______________________________________________             ______________________
  c)  ________________________________________________             ______________________
  d)   _______________________________________________             ______________________

Total Proposed Expenditures:                                       ______________________

Form NAA-01 (Rev. 02/22)                                                                   Page 3 of 5
                         Visit us at portal.ct.gov/DRS for more information.

Part IV — Municipal Information

To be completed by the municipal agency overseeing implementation of the program

 Name of municipal agency overseeing implementation of the program:  _______________________

   ___________________________________________________________________________________

 Mailing address:  ______________________________________________________________________

   ___________________________________________________________________________________

 Name of municipal liaison:  _____________________________________________________________

 Telephone number:  ___________________________________________________________________                                                – –

 Fax number:  _________________________________________________________________________                                                – –

 Email address:  _______________________________________________________________________

                                         Post-Project Audit

                         Is a post-project audit required for this proposal?

                              Yes                                No

                            If Yes, date post-project audit due:

                                        _________________________ 
                                          Date

Form NAA-01 (Rev. 02/22)                                                        Page 4 of 5
                            Visit us at portal.ct.gov/DRS for more information.

                  2022 Connecticut Neighborhood Assistance Act (NAA)
                                            Program Proposal
                                            Instructions

Complete all items on Form NAA-01, 2022 Connecticut Neighborhood Assistance Act (NAA) Program Proposal. 
Incomplete applications will not be accepted. For where to direct inquiries, see For Further Information below.

Part I  —General Information                              This  amount  may  not  exceed  the  total  proposed 
                                                          expenditures. Please note that the minimum NAA 
Enter  the  name  of  the  tax  exempt  organization 
                                                          funding is $250, with a maximum funding of $150,000 
or  municipal  agency,  address,  Federal  Employer 
                                                          per organization or agency per year.
Identification Number, and email address.
Program Title: Assign a unique program title to each      Other Funding Sources:   Provide a detailed 
                                                          description(s) and the amount(s) of all funding sources.
program for which your organization is making an 
application.                                              Proposed Program Expenditures: The budget must 
                                                          include a detailed description and the amount of all 
Federal Form 990: Attach a copy of the first page of 
                                                          direct operating  and  administrative expenditures.  
your organization’s most recent federal Form 990 or 
Form 990EZ. If your organization is not required to file  Expenditures must equal or exceed total funding.
either Form 990 or Form 990EZ, attach a copy of the       Direct Operating Expenses:      Expenses include 
determination letter from the Internal Revenue Service.   materials, equipment, wages, salaries, tuition fees, 
                                                          sub-contracting services, and any other expenses 
Part II  —Program Information                             needed to administer the program.
Description  of  Program:    Describe  the  program, 
including information about how the program will          Part IV  —Municipal Information
operate, its benefit to the community, how recipients     This part is to be completed by the municipal agency 
will be selected, and any measures used to determine      overseeing implementation of the program.
the program’s impact on the community.                    Municipal Liaison: The municipality must designate 
Need for Program:        Demonstrate a need for this      an individual to serve as a liaison with DRS for all 
program. For example, provide relevant statistics.        NAA matters.
Neighborhood Area to Be Served:     Describe the          Post-Project Audit: Any program receiving $25,000 
neighborhood or municipality this program will serve.     or  more  in  NAA  funding  is  required  to  provide  a 
                                                          post-project  audit, prepared by a  certified public 
Plan to implement the program:      Describe how 
                                                          accounting firm, to the municipality overseeing 
the program will operate. Identify other persons or 
                                                          the program. This audit must be submitted to the 
organizations  involved  in  the  administration  of  the 
                                                          municipality no later than three months after the 
program.
                                                          program completion date.
Timetable: Indicate the starting and completion dates 
of the program. The program completion date must not      For Further Information
be more than two years from the program start date.
                                                          Email inquiries to:
Part III  —Financial Information                          •  NAAProgram@ct.gov
Each program proposal must include a program budget       or call DRS Monday through Friday, 8:30  a.m. to 
that includes all sources of funding and all anticipated  4:30 p.m. at:
expenditures. The information provided in the budget      •  860-297-5687
may be used during a post-project audit.                  •  860-297-4911    (TTY, TDD,  and Text Telephone 
Sources of Revenue:      The budget must include the         users only, let the 711 relay operator know the 
requested NAA funding and any other anticipated              number you wish to call and the relay operator will 
revenue sources.                                             dial it and then communicate using a TTY.)
NAA Funding Requested: Indicate the total amount 
your organization is requesting for its program.

Form NAA-01 (Rev. 02/22)                                                                                Page 5 of 5
                                Visit us at portal.ct.gov/DRS for more information.