1) How much is your weekly rent? (to the nearest hundred) £100£200£300£400£500£600£700 2) How many rooms are affected by the disrepair? 123456789 3) Which rooms are affected by the disrepair? BedroomsLiving RoomsHallwayBathroomKitchen 4) What is the type of disrepair? Inadequate Heating and/ or Hot WaterDampRoof LeaksWater LeaksBlocked Pipes and/or DrainsStructural ProblemsElectrical IssuesOthers 5) When did you first report the disrepair to your landlord? 6) How long has there been disrepair at the property? (to the nearest year) Over 1 Year2 Years3 Years4 YearsOver 5 Years 7) How severe is the disrepair? (5 being the highest)? 12345 8) Has your repair been rectified? YesNo 9) Approximately, what is the replacement value of your personal belongings that have damaged by the disrepair? None£100£200£300£400£500Above £600 Who is your landlord? Housing AssociationLocal AuthorityPrivate Landlord Please Upload images/Videos of any damage in your property that has not yet been fixed? Conveyancing Wills and Trust Work Related Illness Housing Disrepair Personal Injury