Title Page
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Conducted on
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Prepared by
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Address (inc post code)
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Client Name(s)
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Date of Birth(s):
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Client Home phone/Mobile
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Client e-mail address
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Name of Landlord (Must be Council or Housing Association)
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Have you ever made a claim for Housing Disrepair before?
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Are you planning on moving out in the next 12 months?
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Have you been complaining of the disrepair for at least 6 months?
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Any rent arrears?
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If rent arrears how much?
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Single or Joint Tenancy?
Reporting
ABOUT THE DISREAPIR
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Internal Disrepairs - i.e Living room/ bedrooms/ toilet etc
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External - DETAILS OF DISREPAIR & CAUSE eg: Leaking roof, missing tiles, Structural Cracks, Chimney, DPC, Roof, Guttering, Brickwork, Soffit, Facias
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Hallway/Stairs/Landing - DETAILS OF DISREPAIR & CAUSE eg Front Door, Stairs, Landing, Ceiling, Windows, Gable end Wall
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Kitchen - DETAILS OF DISREPAIR & CAUSE eg: Extractor Fan, Kitchen Cupboards, Boiler, DPC, Windows, Back Door, Electrics, Tiles
Photographs
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