How Much Do You Pay In Rent Every Month?(Required)(To The Nearest Hundred) £ How many rooms in the property?(Required)How many months or years have you lived in the property? 3 Months 6 Months 12 Months 1 year+ Which Rooms Are Affected by Disrepair?(Required) Bedrooms Living Rooms Hallway Bathroom Kitchen How Many Rooms Are Uninhabitable?(Required)What Is The Type Of Disrepair?(Required) Damp Roof Leaks Electrical Hazards Water Leaks And Blocked Pipe Inadequate Heating AND/OR Hot Water Blocked Drains Mould Structural Defects Other When did you first report the disrepair to your landlord?(Required) DD slash MM slash YYYY How long has there been disrepair? (to the nearest year)(Required) What is the severity of disrepair? (5 being the highest)?(Required) Has your repair been rectified?(Required) Yes No Is the disrepair causing any serious risk of harm to your health and safety?(Required) Yes No First Name Last Name Contact Number Email address TotalPer MonthTotalPer MonthTotalPer MonthTotalPer Month
