Title Page
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Site Visit?
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Reference:
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Client Name:
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Client NI Number:
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Client Home phone/Mobile
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Client e-mail:
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Client date of birth:
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Client occupation:
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PROPERTY & TENANCY ASSESSMENT
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Address of property:
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Type of property:
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If flat / Tower block which floor do you live on:
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Status in property: SINGLE/JOINT
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Type of tenancy Agreement:
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Monthly/weekly rent:
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Any rent arrears and amount:
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Have arrears resulted in any court action:
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Date tenancy agreement started:
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Do you have a copy of your tenancy agreement:
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Name and address of landlord / council / housing association:
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How many downstairs rooms are there in the property if applicable
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How many bedrooms are in the property:
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LIST OF DEFECTS & OTHER INFO
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Room Name
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Room Name
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Room Name
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Room Name
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Room Name
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Room Name
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Room Name
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Gas Safety
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External
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When did you notice the defect / disrepair:
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Has the landlord been informed of the dis-repair:
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If so, how and when:
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How many times have you contacted the landlord about the disrepair in total:
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Do you have any evidence of the notice (copy letters / emails):
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Has your landlord inspected your property following notification of the defect:
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If so, when and what action was taken:
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Have you ever reported the defects to your local councils Environmental Health Department
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If yes, what action did they take?
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What heating installations do you have in the property:
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Is it working:
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If not working, what is wrong:
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Do you use the heating:
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If not, why:
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FIXTURES & FITTINGS
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Do all baths, toilets and sinks work in the property:
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If no - details
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PERSONAL INJURY / HEALTH ISSUES
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Has anyone had health issues because of the disrepair:
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If yes, who has been affected and what are the health issues
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Have the symptoms been reported to their GP or any hospital:
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Has this led to any medication being prescribed:
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If yes, what medication:
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Name and address of GP:
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Name and address of any hospital:
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PERSONAL EFFECTS - DAMAGE
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Have any personal effects been damaged by the disrepair:
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ID/Proof of Address (dated within last 4 months)
