The Assured Tenancies and Agricultural Occupancies (Forms) Regulations 1997

FORM No. 5 E+W

Housing Act 1988 section 13(4)

Application referring a Notice proposing a new rent under an Assured Periodic Tenancy or Agricultural Occupancy to a Rent Assessment Committee E+W

•Please write clearly in black ink •Please tick boxes where appropriate and cross out text marked with an asterisk (*) that does not apply. •This form should be used when your landlord has served notice on you proposing a new rent under an assured periodic tenancy, including an assured shorthold periodic tenancy

•This form may also be used to refer a notice proposing a new rent or licence fee for an assured periodic agricultural occupancy. In such a case references to “landlord"/ “tenant" can be read as references to “licensor"/ “licensee" etc. •This form must be completed and sent to your local rent assessment panel—with a copy of the notice served on you proposing the new rent—before the date it is proposed that the new rent will take effect.

1.  Address of premises: E+W

....................

....................

....................

2.  Name(s) of landlord(s)/agent*: E+W

....................

....................

Address of landlord(s)/agent*:

....................

....................

....................

....................

3.  Details of premises. E+W

(a) What type of accommodation do you rent?

Room(s)□	Flat□	Terraced House□
Semi-Detached House□	Fully Detached House□	Other(Please specify)□

(b) If it is a flat or room(s) what floor(s) is it on?

Ground□ First□ Second□ Other□(Please specify)

(c) Give the number and type of rooms, eg living room, bathroom etc.

....................

....................

(d) Does the tenancy include any other facilities, eg garden, garage or other separate building or land?

Yes□ No□

(e) If yes, please give details:

....................

....................

(f) Do you share any accommodation with

(i)the landlord?	Yes□	No□
(ii)another tenant or tenants?	Yes□	No□

(g) If yes to either of the above, please give details:

....................

....................

4.  When did the present tenancy begin? E+W

....................

5.—(a) Did you pay a premium? E+W

Yes□ No□

• a premium is a payment which is additional to rent and is equivalent to more than two months rent. It may give you the right to assign the tenancy (pass it on to someone else) unless the tenancy agreement states or implies otherwise.

(b) If yes, please give details:

....................

....................

....................

6.  Services E+W

(a) Are any services provided under the tenancy (eg cleaning, lighting, heating, hot water or gardening)?

Yes□ No□

(b) If yes, please give details:

....................

....................

....................

(c) If yes, is a separate charge made for services, maintenance, repairs, landlord’s costs of management or any other item?

Yes□ No□

(d)What charge is payable?	£....................	per ....................
	(e.g. week, month, year)

(e) Does the charge vary according to the relevant costs?

Yes□ No□

(f) If yes, please give details:

....................

....................

....................

7.—(a) Is any furniture provided under the tenancy? E+W

Yes□ No□

(b) If yes, please give details. Continue on a separate sheet if necessary or attach a copy of the inventory:

....................

....................

....................

8.  Improvements E+W

(a) Have you, or any former tenant(s) carried out improvements or replaced fixtures, fittings or furniture for which you or they were not responsible under the terms of the tenancy?

Yes□ No□

(b) If yes, please give details. Continue on a separate sheet if necessary:

....................

....................

....................

9.  What repairs are the responsibility of: E+W

(a) the landlord?

....................

....................

....................

(b) the tenant?

....................

....................

....................

10. (a)Is there a written tenancy agreement?

Yes□

No□

(b) If yes, please attach the tenancy agreement (with a note of any variations). It will be returned to you as soon as possible.

11.  Do you have an assured agricultural occupancy? E+W

Yes□ No□

12.—(a) I/we* attach a copy of the notice proposing a new rent under the assured periodic tenancy and I/we* apply for it to be considered by the rent assessment committee. E+W

Signed .................... .................... ....................

Date ....................

To be signed and dated by the tenant or his agent. If there are joint tenants each tenant or the agent must sign unless one signs on behalf of the rest with their agreement.

Please specify whether: tenant□ joint tenants□ tenant’s agent□

(b) Name and address of tenant(s) referring to the rent assessment committee.

Name(s) (Block Capitals)

....................

....................

....................

Address

....................

....................

....................

Telephone—Daytime....................