Help For Housing Disrepair Form

• TItle

• Tenant name

• D.O.B.

• Address

• Phone number

• Email

• Photo ID

  Media

• POA

  Media

• Tenancy agreement

  Media

• Property type:

• Tenancy Type:

• Are you named in the tenancy?

  Yes

  No

  N/A

• How much is the rent?

• Date Tenancy started: (Must be over 1 Year)

  Date

• Do you have a copy of the tenancy agreement?

  Yes

  No

  N/A

• Rent Amount: (Including benefits)

• Rent Arrears:

• Name:

• Why we believe this is a case?

• Has it been reported?

  Yes

  No

  N/A

• Did the landlord respond? - If yes, please give details

• Date 1st Reported?

• Are the photos of the current state in your property?

  Yes

  No

  N/A

• Is there damp in the property? - If so, please give details

  Yes

  No

  N/A

• When was this reported?

  Date

• How many rooms affected?

• Living Room - If so, please give details

  Yes

  No

  N/A

• Dining Room - If so, please give details

  Yes

  No

  N/A

• Kitchen - If so, please give details

  Yes

  No

  N/A

• Bedroom 1 - If so, please give details

  Yes

  No

  N/A

• Bedroom 2 - If so, please give details

  Yes

  No

  N/A

• Bedroom 3 - If so, please give details

  Yes

  No

  N/A

• Bedroom 4 - If so, please give details

  Yes

  No

  N/A

• Bathroom? - If so, please give details

• Are there any leaks in the property? - If so, please give details

• Is there loose or broken roof tiles? - If so, please give details

• Is there cracks to external walls? - If so, please give details

• Is there cracks to internal walls? - If so, please give details

• Are there faulty electrics? - If so, please give details

• Is the boiler faulty? - If so, please give details

  Yes

  No

  N/A

• Are any sanitary fixtures broken? - If so, please give details

  Yes

  No

  N/A

• Are any floorboards roting? - If so, please give details

  Yes

  No

  N/A

• Are there any vermin? - If so, please give details

  Yes

  No

  N/A

• Is there any damage to the property? - If so, please give details

  Yes

  No

  N/A

• Summary of Disrepair:

• Has the disrepair affected your routine?

• Has the disrepair affected your health? If so, how?

• Has it affected other people in your household?

• Has any personal property been damaged? If yes, please provide details?

• Additional info you feel is relevant to the case?

Please note the location of disrepair

• Add media

  Media