Fillable 2020 Neighborhood Assistance Act Program Application (Town of East Hartford)

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2020 Neighborhood Assistance Act Program Application (Town of East Hartford)

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Municipality: _______________________________
Form NAA-01
2020 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 Identication Number: ______________________________________________________
Program title: _____________________________________________________________________________
Name of contact person: ___________________________________________________________________
Telephone number: ________________________________________________________________________
Email address: ____________________________________________________________________________
Total NAA funding requested ($250 minimum, $150,000 maximum): $ __________________________
Department of Revenue Services
State of Connecticut
(Rev. 02/20)
Is your organization required to le federal Form 990 or 990EZ, Return of Organization Exempt
from Income Tax?
Yes No
If Yes, attach a copy of the rst page of your most recent return.
If No, attach a copy of your determination letter from the U.S. Treasury Department, Internal
Revenue Service.
– –
Print Form
Reset Form
Town of East Hartford
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. 02/20) Page 2 of 5
Timetable:
Program start date: __________________________________
Program completion date: ____________________________
The program completion date must not be more than two years from the program start date. A certied
post-project review 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. 02/20) Page 3 of 5
Form NAA-01 (Rev. 02/20) Page 4 of 5
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 Review
Is a post-project review required for this proposal?
Yes
No
If Yes, date post-project review due:
_________________________
Date
Town of East Hartford Grants Administration Office
740 Main Street, East Hartford, CT 06108
Grants Manager Paul O'Sullivan
860-291-7206
Page 5 of 5Form NAA-01 (Rev. 02/20)
2020 Connecticut Neighborhood Assistance Act (NAA)
Program Proposal
Instructions
Complete all items on Form NAA-01, 2020 Connecticut Neighborhood Assistance Act (NAA) Program Proposal.
Incomplete applications will not be accepted. For where to direct inquiries, see Contact Information below.
Part I
—
General Information
Enter the name of the tax exempt organization
or municipal agency, address, Federal Employer
Identication Number, and email address.
Program Title: Assign a unique program title to each
program for which your organization is making an
application.
Federal Form 990: Attach a copy of the rst page of
your organization’s most recent federal Form 990 or
Form 990EZ. If your organization is not required to le
either Form 990 or Form 990EZ, attach a copy of the
determination letter from the Internal Revenue Service.
Part II
—
Program Information
Description of Program: Describe the program,
including information about how the program will
operate, its benet to the community, how recipients
will be selected, and any measures used to determine
the program’s impact on the community.
Need for Program: Demonstrate a need for this
program. For example, provide relevant statistics.
Neighborhood Area to Be Served: Describe the
neighborhood or municipality this program will serve.
Plan to implement the program: Describe how
the program will operate. Identify other persons or
organizations involved in the administration of the
program.
Timetable: Indicate the starting and completion dates
of the program. The program completion date must not
be more than two years from the program start date.
Part III
—
Financial Information
Each program proposal must include a program budget
that includes all sources of funding and all anticipated
expenditures. The information provided in the budget
may be used during a post-project audit.
Sources of Revenue: The budget must include the
requested NAA funding and any other anticipated
revenue sources.
NAA Funding Requested: Indicate the total amount
your organization is requesting for its program.
This amount may not exceed the total proposed
expenditures. Please note that the minimum NAA
funding is $250, with a maximum funding of $150,000
per organization or agency per year.
Other Funding Sources: Provide a detailed
description(s) and the amount(s) of all funding sources.
Proposed Program Expenditures: The budget must
include a detailed description and the amount of all
direct operating and administrative expenditures.
Expenditures must equal or exceed total funding.
Direct Operating Expenses: Expenses include
materials, equipment, wages, salaries, tuition fees,
sub-contracting services, and any other expenses
needed to administer the program.
Part IV
—
Municipal Information
This part is to be completed by the municipal agency
overseeing implementation of the program.
Municipal Liaison: The municipality must designate
an individual to serve as a liaison with DRS for all
NAA matters.
Post-Project Review: Any program receiving $25,000
or more in NAA funding is required to provide a
post-project review, prepared by a certied public
accounting rm, to the municipality overseeing the
program. This review must be submitted to the
municipality no later than three months after the
program completion date.
Contact Information
Direct inquiries to:
Department of Revenue Services (DRS)
Neighborhood Assistance Act Program
Attn: Research Unit
450 Columbus Blvd Ste 1
Hartford CT 06103-1837
or call 860-297-5687.
TTY, TDD, and Text Telephone users only may
transmit inquiries anytime by calling 860-297-4911.
Taxpayers may also call 711 for relay services. A
taxpayer must tell the 711 operator the number he or
she wishes to call. The relay operator will dial it and
then communicate using a TTY with the taxpayer.
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2020 Neighborhood Assistance Act Program Application (Town of East Hartford)

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Completed 15 July 2020

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