Connecticut Neighborhood Assistance Act (NAA-02) Form

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Connecticut Neighborhood Assistance Act (NAA-02) Form

Business Firm Information

Business Name Street Address 1 Street Address 2 City State Zip Code CT Tax Registration Number Name of Contact Person Telephone Number Title Email Address of Contact Person May DRS approve this application through an email to your contact person? Yes No Enter Income Year Beginning Enter Income Year Ending Type of Business C Corporation Other (specify) Other Tax type against which the credit will be used Corporation Business Tax Insurance Premiums Tax Public Service Companies Tax

Program Proposal Information

Municipality Approving Program Organization/Municipal Agency Program Title Amount of Cash Contribution Credit Percentage of Contribution

Signature

Authorized Representative’s Name (Print) Authorized Representative’s Title Date Check here if you would like to complete another form for this entity.

Connecticut State Department of Revenue Services