Housing disrepair claim form

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Clients details

• Clients full name

• Clients phone numbers

• Clients email

• Client’s date of birth

• Clients address
  Address

Tenancy

• Tenancy

• Property type

• Who is on tenancy

• Copy of tenancy

  Media

• Date tenancy started

• How much is the rent a month

• Are you in areas with rent

• Landlord name

• Landlord phone number

• Landlord email

• Landlord address

Defect details

Location 1

• Describe the property’s defects

• Have you reported ( date)

• Response from landlord

• How many times reported to landlord

• How has this effected your daily life

• Describe how it has effected your health and family members

• Have you sort medical attention

• Describe how it has effected your health

• Has any of your belongings been effected (cost)

Location 2

• Location 2

• Describe property defects

• Have you reported (date)

• Response from landlord

• How many times reported to landlord

• How has the defects effected your daily life

• Describe how it has effected your health and family members

• Have you sort medical attention

• Describe how it has effected your health

• Has any of your belongings been effected (cost)

Location 3

• Describe property defects

• Have you reported ( date)

• Response from landlord

• How many times reported to landlord

• How has this effected your daily life

• Describe how it has effected your health and family members

• Have you sort medical attention

• Describe how it has effected your health

• Has any of your belongings been effected (cost)

Location 4

• Describe property defects

• Have you reported (date)

• Response from landlord

• How many times reported to landlord

• How has this effected your daily life

• Describe how it has effected your health and family members

• Have you sort medical attention

• Describe how it has effected your health

• Has any of your belongings been effected (cost)

Location 5

• Describe property defects

• Have you reported ( date)

• Response from landlord

• How many times reported to landlord

• How has this effected your daily life

• Describe how it has effected your health and family members

• Have you sort medical attention

• Describe how it has effected your health

• Have you sort medical attention

• Has any of your belongings been effected (cost)

Location 6

• Describe property defects

• Have you reported ( date)

• Response from landlord

• How many times reported to landlord

• How has this effected your daily life

• Describe how it has effected your health and family members

• Have you sort medical attention

• Has any of your belongings been effected (cost)

Location 7

• Describe property defects

• Have you reported ( date)

• Response from landlord

• How many times reported to landlord

• How has this effected your daily life

• Describe how it has effected your health and family members

• Have you sort medical attention

• Has any of your belongings been effected (cost)

Location 8

• Describe property defects

• Have you reported ( date)

• Response from landlord

• How many times reported to landlord

• How has this effected your daily life

• Describe how it has effected your health and family members

• Have you sort medical attention

• Has any of your belongings been effected (cost)

Friends and family

• Name

• Phone number

• Name

• Phone number