Step 1 of 8 12% Today's Date Day Month Year Have you sought legal advice for disrepair in relation to this property:NoYesIf yes, please provide details: Are you planning on remaining in the property for the next 12 months? (If Yes, please provide details)NoYes SECTION 2 – Tenant/Occupier Details:Title* First Name* Surname:* Full Address Date Of Birth Day Month Year Mobile:*Alternative Contact* Email Address:* Do you receive any benefits?*YesNoIf yes, please provide details: SECTION 3 – Tenancy Details:Tenancy Type:SingleJointIf Joint Tenancy, please provide details of other tenants below:If Joint Tenancy please enter Full Name and D.O.B of each person on the Tenancy AgreementTenancy Commencement Date:*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Do you have a copy of the Tenancy Agreement*YesNoif yes, please provide What is the rent (week / month): Per Week*Are you in arrears? If so, how much?* Has your landlord ever started court proceedings against you:YesNoName and contact details of landlord:Details of any Legal proceedings: SECTION 4 – Property details:Property Type:*BungalowDetachedFlatTerracedSemi DetachedOtherNumber of living rooms:* Number of bedrooms:* Number of people living at the property:* SECTION 5 – General overview:Have you previously notified the landlord of any outstanding works?YesNoDid any maintenance work get carried out?NoYesIf yes, please provide details: Have you previously notified the landlord of any outstanding works?YesNoHave the problem/s returned since they were completed?NoYesIf yes, how many times have you faced the problem/s? Additional Information:* SECTION 6 – Type of disrepair (Exterior):What type of disrepair is present (please circle below all that apply) , include cause of damage if known Roof damage Subsidence Defective windows Damp Rotten Woodwork Guttering problems Drains Japanese Knotweed Other If other, please provide details When did you first notice the problem/s?*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920When did you first inform the landlord?*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920(please include exact dates if possible)How did you inform the landlord Letter email Telephone Housing Office Other What was the landlords response:* Has the problem/s been fixed?YesNoIf no, have you followed up with the landlord (detail chase method):* SECTION 7 – Type of disrepair (Interior):Room/s affected (please detail each):*What type/s of disrepair are present (please provide details below for each room), include cause of damage if knownRoom Details:What type of disrepair is present Plaster work Mould growth Defective windows Damp Heating – Radiators Rotten woodwork Electrical fittings Water leak Fittings and installations Japanese Knotweed Other If other, please provide details: When did you first notice the problem/s?*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920When did you last inform the landlord?*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920(please include exact dates if possible)How did you inform the landlord Letter Email Telephone Housing Office Other What Was The Landlords Response: Has the problem/s been fixed?YesNoIf no, have you followed up with the landlord (detail chase method): SECTION 8 – Personal/Health impacts:Have you or your family had any health issues because of the disrepair?*YesNoHave you visited the GP or a medical expert because of the health issues?*NoYesIf yes, please provide details: CAPTCHA
