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Housing Disrepair Appointment Form
Contact Details
Full Name
Address
Date of Birth
Email
Contact Number
Alternative Contact Number
Occupation
Employed
Self-employed
Retired
Universal Credit / other benefit
Tenancy
Tenancy Type
Single Tenancy
Joint Tenancy
Joint Tenants Date of Birth
Joint Tenants Name
Joint Tenants Contact Number
Joint Tenants Email Address
Speaking on tenants behalf
Is someone speaking on the tenants behalf?
Yes
No
Name of spokesperson
Relationship with tenant
Key Questions
Source / Name of agent
Have you instructed any Sols previously fo a housing disrepair claim?
Yes
No
Are you currently on a waiting list to be Re-housed?
Yes
No
Is this permanent property?
Yes
No
Are you in Rent arrears?
Yes
No
Do you have a PP set up
Yes
No
Is the damage to your property on going?
Yes
No
Do you currently have any repairs booked in?
Yes
No
Tell us about your housing disrepair claim
Name of council or housing association
Property Type
House
Flat
Bungalow
Flat / House position
Top Floor
Ground Floor
How many rooms in property
Do you have the following:
Front / Back Garden
Garage / Driveway
What type of roof
Pitched
Flat
Out-house / Coal / Brick Shed
Paths and fencing
Communal Entrances / Stairwell
Issues within the property
Area of Damage
First Notice
Causation
2nd Area of Damage
First Notice
Causation
3rd Area of Damage
First Notice
Causation
Submit Form
