Housing Disrepair Claim Form

1. Personal Details

Full Name * Please enter your full name

Date of Birth * Please enter your date of birth

Phone Number * Please enter your phone number

Email Address * Please enter a valid email address

Current Address (including postcode) * Please enter your current address

How long have you lived at this property? * Please select duration

2. Tenancy Information

Type of tenancy *

Council Housing Association Private Rented Other (please specify)

Please select your tenancy type

Please specify your tenancy type

Landlord's name * Please enter landlord's name

Letting agent (if applicable)

Date tenancy started * Please enter tenancy start date

Is your tenancy: *

Fixed-term Periodic (rolling)

Please select tenancy period

Monthly rent amount * Please enter monthly rent amount

Are you up to date with rent payments? *

Yes No

Please select rent payment status

If no, please provide details

3. Property Details

Property type *

House Flat Bedsit Other (please specify)

Please select property type

Please specify property type

Number of bedrooms * Please select number of bedrooms

Number of occupants * Please enter number of occupants

Ages of occupants (especially children or elderly)

4. Nature of the Disrepair

Select all issues that apply to your property

Please describe other disrepair issues

Detailed Description * Please provide a detailed description

Where in the property are they located? * Please specify location of disrepair

How severe are they? * Please select severity level

5. Timeline of Issues

When did the problem(s) first start? * Please enter when issues started

Have the issues worsened over time? *

Yes No

Please select if issues have worsened

If yes, explain how

6. Reporting History

Have you reported the issue(s) to your landlord? *

Yes No

Please select if you reported to landlord

Date first reported * Please enter first report date

Method of reporting *

Phone Email Letter Online Portal

Please select reporting method

Have you reported it more than once? *

Yes No

Please select if multiple reports were made

Provide dates of follow-ups

7. Landlord Response

Has the landlord attempted repairs? *

Yes No

Please select if landlord attempted repairs

When were repairs attempted?

What work was done?

Were the repairs successful? *

Yes No

Please select if repairs were successful

If no, explain why

8. Impact on You

Health Effects

Have you or anyone in your household experienced health problems? *

Yes No

Please select if health problems occurred

Describe symptoms

Has a doctor been consulted? *

Yes No

Please select if doctor was consulted

Daily Living Impact

Are any rooms unusable? *

Yes No

Please select if rooms are unusable

Are you unable to heat your home properly? *

Yes No

Please select if heating is affected

Has it affected your sleep, work, or daily life? *

Yes No

Please select if daily life is affected

Provide details

9. Financial Losses

Have you suffered financial losses due to disrepair? *

Yes No

Please select if you suffered financial losses

Damaged belongings Increased energy bills Medical expenses Other costs

Specify financial losses