Dispair Aduit Please enable JavaScript in your browser to complete this form.Date of InspectionCompleted byHave you sought previous legal advice for this repair before?YES NOName of Practice?Tenant/Occupier DetailsTitle - Mr Mrs Miss Ms OtherFirst Name *SurnameTenancySingleJointContact NumberAddressPostcodeE-Mail Address *Date of BirthNational Insurance NumberIs the tenant on benefits? Yes NoList BenefitsTenant DetailsDate of tenancy startedCan you provide a copy of the tenancy agreementYes NoAgreement ProvidedYes NoAgreement to be emailedYes NoHow much is your rent?WeekelyMonthlyHave you ever had court proceedings issues against you?Yes NoLandlord DetailsName of LandlordAddressPostcodeEmailContact NumberType of propertyBungalowFlatCottageOtherDetachedEnd of TerraceDefect DetailsPlease see below the Landlords responsibilities- The structure and exterior of your home, the walls, roof, foundations, drains guttering, external pipes, windows and external doors. Basins Sinks, Toilet and their pipework. Water, Gas Pipes, Electrical Wiring, and Water tanks, Boilers, Radiators, Gas Fires, Fitted electric fires or fitter heaters Please Make sure these are listed in the claim form and that the landlord has been notified of the disrepair, if not the claim will be rejected.Room 1Room NameDisrepair to the room (if damp provide meter readings)When was it reported? (Precise Date)How was it reported? (Phone, face to face, email)Images of Disrepair (most Recent) Click or drag files to this area to upload. You can upload up to 20 files. Room 2Room NameDisrepair to the room (if damp provide meter readings)When was it reported? (Precise Date)How was it reported? (Phone, face to face, email)Images of Disrepair (most Recent) Click or drag files to this area to upload. You can upload up to 20 files. Room 3Room NameDisrepair to the room (if damp provide meter readings)When was it reported? (Precise Date)How was it reported? (Phone, face to face, email)Images of Disrepair (most Recent) Click or drag files to this area to upload. You can upload up to 20 files. Room 4Room NameDisrepair to the room (if damp provide meter readings)When was it reported? (Precise Date)How was it reported? (Phone, face to face, email)Images of Disrepair (most Recent) Click or drag files to this area to upload. You can upload up to 20 files. Room 5Room NameDisrepair to the room (if damp provide meter readings)When was it reported? (Precise Date)How was it reported? (Phone, face to face, email)Images of Disrepair (most Recent) Click or drag files to this area to upload. You can upload up to 20 files. When did you first notice the defects? (Exact Date, be as precise as possible)Date:How many rooms does your defect affect?Have you reported this to your Landlord?Did your Landlord respond to your reporting the defect?If your Landlord responded to you do have a copy of the response?How many times have you contacted your Landlord with regards to your defect?Can you provide a list of dates and correspondance that you have sent to your Landlord?Can you provide a list of dates and correspondance that you have sent to your Landlord?Yes NoHas your Health affected by your defects?Are they any other members of the household claiming for ill health due to the defects?Submit
