Redevelopment Authority ofthe County ofBerks  400 E. Wyomissing Avenue Ground Floor, Suite #2 Mohnton, PA 19540 BOARD MEMBERS Glenn Yeager, Chairman Eileen Kastura, Vice Chairman Diodato Bassano, Treasurer Thomas R. Ruth, Secretary Jorge Diaz, Assistant Secretary/Treasurer  Phone (610) 478-6325 Fax (610) 478-6326 website: www.co.berkspa.us Kenneth Pick, Executive Director Daniel Becker, Esq., Solicitor  Major Systems Program  On behalf ofthe County of Berks, the Redevelopment Authority oft the County of Berks (BCRA) is administering the Major Systems Program. The Program is designed to assist low-income families who own and occupy an attached or detached single-family home in need ofa repair or replacement ofai major system oftheir house. This assistance is in the form of a one-time deferred payment loan and must be used for an item or items that threatens the health, safety, or welfare ofthe household. The house must be located in a borough or township of Berks County. The Program may be funded by federal, state, or  local sources. Eligible Uses:  Replace or Repair Roof Replace or Repair Heating System Mechanical Repairs and Structural Items ADA Fixtures and Ramps  Please see the front desk for an intake form.  All forms can be mailed to the Berks County Redevelopment Authority.  400 E. Wyomissing Avenue Ground Floor, Suite #2 Mohnton, PA 19540  For more information and to find a printable intake form: htps/www.co.berks.p.uydeptherksra    MUNICIPALITY:  PHONE NUMBER:  REDEVELOPMENT AUTHORITY OF THE COUNTY OF BERKS MAJOR: SYSTEMS PROGRAM. APPLICATION  Date of Interview:, Applicant's Name (s): Address:  Interviewer:, Age: S.S.#: S.S.#:  Phone #:  (1) (2)  Ist the property in one name or both names: Names and ages of all persons living in the household:  Isthis your principal residence? Yes D No D  Have you previously applied for the Program? Yes D No D Did you receive assistance: Yes D No D  At what banks do you have accounts?. Checking Account Balance:  Savings Balance:  Stocks/Bonds:  Adjusted Gross Income from IRS Form 1040 Individual Income Tax Return:  What home repairs or replacements are needed?  I(we) certify that the above information is true and correct to the best of my (our) knowledge and belief. (we) hereby authorize the Redevelopment Authority to obtain verification of any and alli information contained on  this form.  WARNING: PENALTY FOR FALSE OR FRAUDULENT STATEMENTS  Any false, fictitious or fraudulent statements or representations made knowingly or willfully may subject the  signer to penalties under Section of 1001 of Title 18 of the United States Code.  Signature: Print Name: Signature: Print Name:  Date:  Date: