Warm Housing Claim Form

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

Full Name

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Telephone

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• Email Address

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• DOB

Full Address & Postcode

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• Are you a housing association/council tenant? (tenant can only proceed if they live in social housing)

  Yes

  No

• Is your tenancy agreement permanent? (tenancy must be permanent in order to proceed)

  Yes

  No

• Is it a single or joint tenancy agreement?

  Single

  Joint

• Please give full name and date of birth of the joint tenant

• Have you ever made a claim for Housing Disrepair before?

  Yes

  No

• How long ago did you make this claim, and was it for the same disrepairs? (if it less than 12 months, you cannot proceed)

• Are you planning on moving out in the next 12 months? (tenant cannot proceed with the claim if they are moving out)

  Yes

  No

Name of you Landlord (or social housing agency)

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• Do you have any rent arrears?

  Yes

  No

• How much do you currently owe, and is there a payment plan set up to resolve? (if so, please note down the amount of arrears – it must not go over the threshold of £1000)

• Do you have anyone legally representing you when it comes to your housing disrepair issues? (we cannot process if they have representation)

  Yes

  No

• Have your disrepair issues been ongoing for over 6 months? (if no, we cannot proceed)

  Yes

  No

• Have you previously reported these issues to your landlord or property management? (tenant MUST have reported the issues)

  Yes

  No

• Have any attempts been made to fix the issues by your landlord? (please note how many attempts if any – an active landlord means prospect cannot proceed)

  Yes

  No

• When was the most recent attemp to fix the issues by your landlord?

• Approximately how many times have you complained to your landlord about the disrepairs?

• How long have you lived at your address? (must be 12 months or more to proceed)

• When did you last report these issues?

Living Room (please detail all disrepair and ensure you gather evidence)

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Kitchen (please detail all disrepair and ensure you gather evidence)

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Bathroom (please detail all disrepair and ensure you gather evidence)

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Main Bedroom (please detail all disrepair and ensure you gather evidence)

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Second Bedroom (please detail all disrepair and ensure you gather evidence)

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Room 1 (add room name & detail all disrepair and ensure you gather evidence)

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Room 2 (add room name & detail all disrepair and ensure you gather evidence)

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Room 3 (add room name & detail all disrepair and ensure you gather evidence)

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How did you hear about us?

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  • Internet
  • Facebook
  • Instagram
  • X
  • Tiktok
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  • Other

*By selecting Yes, you agree and confirm that you've made a request for support with your disrepair (if so, our colleagues at HQ will contact you to discuss your case in detail; this is to ascertain how best we can help):

• Yes

  No

• Sadly we cannot proceed!