Title Page
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Client Name
Housing Disrepair Claim Form
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Title
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First Name
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Middle Name
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Last Name
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Date Of Birth
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Email
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Contact Number
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Alt. Contact Number
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Proof Of ID
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Proof Of Address
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Address
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Joint Tenancy?
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First Name
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Middle Name
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Surname
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Date Of Birth
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Proof of ID
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Proof of Address
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Landlord Name
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Landlord Address
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Tenancy Details
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Tenancy Start Date
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Do you have a copy of your tenancy agreement?
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Did you pay a deposit?
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How much rent do you pay?
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How often is this paid?
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Are you in receipt of housing benefit?
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Do you have any arrears?
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Do you have a payment plan in place ?
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How much is your payment towards your arrears each month?
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Property type?
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Damage Summary
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Why you believe this is a case
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Have you complained to the landlord?
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First complained to the landlord Date?
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Last report to Landlord
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Method of reporting
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In the past 3-6 months how many times have you reported these issues?
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Has the landlord responded to complaints?
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Are there loose or broken roof tiles?
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Are there cracks in the external walls?
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Are there cracks in the internal walls?
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Are the extractor fan working? *If not, list each room
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Is there damp or mould?
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Are the doors or window frames rotting?
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Are the doors or window frames broken?
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Are there faulty electrics?
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Is the boiler faulty?
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Is the radiator faulty?
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Are any pipes leaking?
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Are any sanitary fixtures broken?
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Are any floorboards rotting?
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Are any floors unsafe or damaged ?
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Are there any vermin?
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Are there any pest infestations?
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Has the disrepair caused health issues?
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Has the disrepair caused inconvenience?
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Have you signed up with any other solicitors for this matter?
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Other issues you want to tell us?
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Have you had any financial losses due to the disrepair?
Rooms Affected
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Name of Room
- Bathroom
- Kitchen
- Living Room
- Dining Room
- Hallway
- Separate Toilet
- Bedroom 1
- Bedroom 2
- Bedroom 3
- Bedroom 4
- Bedroom 5
- Whole Property
- Utility Room
- Outside
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First Report
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Last Report
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Description of damage
