RENTAL HOUSING TRIBUNAL

Schedule 1

COMPLAINANT FORM FOR THE RENTAL HOUSING TRIBUNAL

FOR OFFICIAL USE ONLY

REFERENCE NO.

A. PARTICULARS OF COMPLAINANT

SURNAME:
__________________________________________________________________________________
FORENAME (S):
____________________________________________________________________________________________
NAME OF ASSOCIATION (S):
_____________________________________________________________________
ID NUMBER / PASSPORT NO:
_____________________________________________________________________
BUSINESS / RESIDENTIAL ADDRESS (FLAT NAME, ROOM NO. STREET NAME):
_____________________________________________________________________

_____________________________________________________________________
CONTACT NUMBER:
_____________________________________________________________________
HOME TELEPHONE NO:
_____________________________________________________________________
FAX NUMBER:
_____________________________________________________________________
EMAIL ADDRESS:

B. DETAILS OF DWELLING

NUMBER OF UNITS IN BUILDING (IF APPLICABLE):

__________________________________________________________________________________
NUMBER OF TENANTS LIVING IN THE DWELLING:
__________________________________________________________________________________
LOCATION OF DWELLING:
__________________________________________________________________________________

__________________________________________________________________________________

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C. PARTICULARS OF TENANT/S COMMITTEE MEMBERS

NAME:
CONTACT NUMBER:

DWELLING:
__________________________________________________________________________________
NAME:

CONTACT NUMBER:

DWELLING:
__________________________________________________________________________________
NAME:

CONTACT NUMBER:

DWELLING:
__________________________________________________________________________________
NAME:

CONTACT NUMBER:

DWELLING:
__________________________________________________________________________________
NAME:

CONTACT NUMBER:

DWELLING:
__________________________________________________________________________________
NAME:

CONTACT NUMBER:

DWELLING:

D. PARTICULARS OF PERSON AGAINST WHOM THE COMPLAINT IS LODGED

NAME OF LANDLORD / TENANT / ASSOCIATION:

__________________________________________________________________________________
CONTACT NUMBER:
__________________________________________________________________________________
FAX NUMBER:
__________________________________________________________________________________
PERMANENT RESIDENTIAL ADDRESS (FLAT NAME, ROOM NO. STREET NAME):
__________________________________________________________________________________

__________________________________________________________________________________
EMAIL ADDRESS:
__________________________________________________________________________________

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E. ADDITIONAL INFORMATION

NAME OF CARETAKER:

CONTACT NUMBER: FAX NUMBER:

__________________________________________________________________________________
NAME OF OWNER OF BUILDING:

CONTACT NUMBER: FAX NUMBER:

PERMANENT RESIDENTIAL ADDRESS (FLAT NAME, ROOM NO. STREET NAME)

POSTAL ADDRESS:
__________________________________________________________________________________
NAME OF MANAGING AGENT:

CONTACT NUMBER: FAX NUMBER:

__________________________________________________________________________________
NAME OF BOND HOLDER:

CONTACT NUMBER: FAX NUMBER:

F. PERSON/ORGANISATION THAT REFERED THE COMPLAINT

NAME:
__________________________________________________________________________________
TEL:
__________________________________________________________________________________
REF NUMBER:
__________________________________________________________________________________

G. LIST OF COMPLAINTS/DISPUTES

1.
________________________________________________________________________________
2.
__________________________________________________________________________________
3.
__________________________________________________________________________________
4.
__________________________________________________________________________________

H. (FINANCIAL STATUS OF BUILDING)

TOTAL ELECTRICITY ARREARS R

__________________________________________________________________________________
TOTAL WATER ARREARS R
__________________________________________________________________________________
TOTAL RATES & TAXES OWED TO COUNCIL R
__________________________________________________________________________________
TOTAL OWED TO THE MANAGEMENT AGENT R

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I. HAS A COMPLAINT FOR THIS BUILDING BEEN SUBMITTED BEFORE?

IF YES WHAT IS THE REFERENCE NUMBER.

YES __________

NO __________

J. IS THERE A NEED FOR INSPECTION?

YES __________

NO __________

NAME OF COMPLAINANT: ___________________________________________________________

SIGNATURE: ______________________________________________________________________

DATE: ____________________________________________________________________________

FOR OFFICIAL USE

NAME OF MEMBER OF STAFF: ______________________________________________________

SIGNATURE: ______________________________________________________________________

DATE: ___________________________________________________________________________

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 STATEMENT FORM

COMPLAINANT ……………………………………………………

RESPONDENT ……………………………………………………

REFERENCE NUMBER ……………………………………………………

COMPLAINANTS ADDRESS ……………………………………………………

……………………………………………………
……………………………………………………

A. CAPACITY

1. Are you lodging this complaint as an individual or tenants' committee?

(Tick the appropriate box) Individual Committee
2. Is the problem common in the building?
If you represent a committee then please let us have this mandate form
completed by the tenants.

B. LEASE AGREEMENT

1. Was this a written or verbal agreement? ……………..

2. Where was the lease agreement entered into? Place: ………………..
3. When was the lease agreement entered into? Date: ………………..
4. When was the first occupation of the dwelling? Date: ………………..
5. What was the agreed period of stay if any? Period: ……………….
6. If a written lease was signed, do you have copy? ……………..
7. If no lease agreement was entered into between you and the landlord, then
what did the landlord tell you before or at the time you rented this dwelling?
………………………………………………..
8. Who did you speak to when you rented this dwelling? Was it the landlord
himself, herself or the agent? Give the name of the person. ………………

C. RENTAL

1. Monthly rental agreement. ……………………………

2. Does the rental include electricity? Yes No
3. Does the rental include water? Yes No
4. By what date should the rental be paid? Date: …………………
5. Where does the rental have to be paid? Place: ………………..
6. To whom does the rental have to be paid? Name: ………………...
7. Is your rental in arrears? Yes No

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 8. Do you have receipts as proof of payment? Yes No
If yes, please provide copies.
If no please provide reasons:
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
………………………………………………………………………………..............
9. How long have you been paying the current rent? Period………………….......
10. Why are you complaining about rental?
……………………………………….……………………………………………...…
…………………………………………………………………………………...……
…………………………………………………………………………..……............
11. Are you paying the same rental as other tenants? Yes No
If no, give reasons why you think you should pay the same as others
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………..........
12. If you think your rent is too high, give reasons why.
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
………………………………………………………………………………..............
13. Does your lease state by how much your rent can be increased?
Yes No
If yes, state the amount…………………………………….
14. How much rent is commonly paid in the area? Amount ±R………………
15. Are there any other services that could have increased your rent?
16. Do you have anything else you wish to add?
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
………………………………………………………………………………..............
In addition to rentals and payments for water and electricity was it agreed that
there would be payments for other services? If so, for what and how much would
have to be paid for each of the services?
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………......................................................

D. MAINTENANCE

1. What are the exact maintenance problems?

…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
………………......................................................................................................
2. Did you have a checklist when you moved in? Yes No No
3. When did the problem of maintenance arise? .......................................
4. Was it discussed with the landlord/agent? ............................................
5. Who did you complain to? Name……………………………………….
6. When did you complain? Date…………………………………………

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 7. What was the response?
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………...........
............................................................................................................................
8. If you are tenants in a block of flats, do you owe rentals? If so, how much is
owing rentals? If so, how much is owed by the tenants? How many tenants
are owing and for how long?
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
……………………………………………………………………………..................

E. SERVICES (WATER, ELECTRICITY, GAS ETC)

1. What are the exact problems?

…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
……………………………………………………………………………..................
2. When did the problem of services first arise?
3. Was it discussed with the landlord?
4. When did you complain?
5. What was the landlord's response?
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
………………………………………………………………………………..............
6. Are you up to date with your rent?
7. Did the landlord agree to provide these services?
8. Any other information relevant to this complaint.
9. Did the landlord take any reasonable steps to correct the situation?
Explain
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
………………………………………………………………………….....................
If you are owing for rentals does it include water, electricity, gas etc or
exclude it? If rentals exclude water, electricity etc how much do you owe for
rentals and how much for water, electricity etc.

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F. DEPOSITS

1. How much deposit was paid?

2. When was the deposit paid?
3. Did you receive a receipt?
4. What is the name of the bank account at which your deposit is held?
5. When did you vacate the dwelling?
6. When was the landlord notified?
7. Was the landlord given a month's notice or the notice period agreed to in
terms of the lease agreement?
8. When was the notice given?
9. Was it a written or verbal notice?
10. When did you ask for a refund of deposit?
11. What was the landlord's response?
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………..........
12. If part of the deposit was refunded, how much was it?
13. Was the deposit refunded with interest?
14. Did the landlord tell you how much interest is due to you?
15. Did you ask the landlord how much interest is due to you?
16. How much was the total deduction?
17. Has the landlord given any details as to part refund?
18. Was an inspection of the dwelling done prior to occupation? If so, when was
this done and by whom?
19. Was a list of all faults and defects drawn up? If so, please provide the list.
20. Were there any repairs done regarding these faults or defects? If so, what
repairs were done?
21. Was a joint inspection of the premises done prior to vacating the premises? If
so, when was this done?
22. Please provide list of defects found on the last inspection done.
23. What was the actual or estimated cost of these faults and defects? Are there
any receipts for these repairs? Let us have these invoices.

G. EVICTION/ISSUING OF SUMMONS

1. When was summons issued against you?

…………………………………………………………………………………..
2. Do you have a copy of the summons?
…………………………………………………………………………………..
3. Were the summons served on you personally?
…………………………………………………………………………………..
4. How were the summons served on you?
………………………………………………………………………………….
5. If no summons, when were you told to vacate the dwelling?
………………………………………………………………………………….
6. Who told you to vacate?
………………………………………………………………………………….
7. Were you given a written notice to vacate?
…………………………………………………………………………………..
8. Has the tenant been evicted? If so, when was he evicted and by whom?
…………………………………………………………………………………..
9. Was he served with a court eviction order? If so, who served this order?
………………………………………………………………………………….

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 10. Where is the evicted person living now?
………………………………………………………………………………….
11. If there is a threat of eviction, when were you notified of this eviction and by
whom?
………………………………………………………………………………….
12. Were you notified verbally or in writing? What were you told?
…………………………………………………………………………………..
…………………………………………………………………………………..
13. Why were you notified about this eviction?
…………………………………………………………………………………..
…………………………………………………………………………………..

H. ATTACHMENT OF PROPERTY

1. Did you receive any notice before your goods and belongings were
attached?
………………………………………………………………………………….
2. When was the notice received? Please supply a copy of the notice.
………………………………………………………………………………….
3. Did you receive any court document such as summons before your goods
and belongings were attached?
………………………………………………………………………………….
4. When did you receive this summons?
…………………………………………………………………………………
5. Who delivered the summons to you?
…………………………………………………………………………………
6. What did you do after the summons was delivered to you?
…………………………………………………………………………………
7. Who attached your goods and belongings?
…………………………………………………………………………………
8. When were they attached?
…………………………………………………………………………………
9. What goods and belongings were attached?
...............................................................................................................
10. Were you served with an order when your goods and belongings were
attached?
……………………………………………………………………………………..
11. Please provide the order of attachment.

I. NON-PAYMENT OF RENT

1. When did this problem of non-payment of rent arise?

2. How much rental is payable?
3. Was the tenant given a written notice to remedy the situation?
4. When was the tenant given a written notice to remedy the situation?
5. Can you provide a copy of such notice?
6. If no copy, please provide reasons
…………………………………………………………………………………………
………………………………………………………………………………..............
7. Is the tenant currently in arrears?
8. BY how much is the tenant currently in arrears?

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J LOCKOUT

1. When were you locked out?

2. Who locked you out?
3. Were you given written notice of the lockout?
4. What was the reason for locking you out?
5. Were your goods also locked in?

_____________________________________________

DECLARATION

I HEREBY SOLEMNLY DECLARE THAT THE INFORMATION SUPPLIED ABOVE

IS TRUE AND CORRECT. I ACCEPT THAT SHOULD ANY INFORMATION
SUPPLIED BY ME BE FOUND TO BE FALSE, THE TRIBUNAL CAN NULLIFY MY
COMPLAINT.

SIGNED …………………… NAME&SURNAME……………………………………..

INFORMATION TAKEN BY ________________________SIGN_____________

INFORMATION SUPPLIED BY _______________________SIGN______________

DATE ________________________

TIME ________________________

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