Address of Property:
Name of Claimant 1:
Name of Claimant 2:
Name of Other Claimants:
Claimant's Address (if different from above)
Claimant's Telephone No:
Claimant's Email Address:

Please identify the name of the road which give rise to your claim:

Which of the following factors are you complaining about? (Please tick box as appropriate):
☐ Noise	☐ Fumes	☐ Artificial Lighting
☐ Vibration	☐ Smell	☐ Smoke
☐ Discharge of a solid or liquid substance
☐ Other – Please specify

Please describe the premises in respect of which the claim is made. If your claim relates to land it will be helpful if you can supply a plan:

Please indicate when the building(s) on the land was/were originally constructed. Have any improvements or extensions been made? If so, please give brief details with dates:

Please indicate the use of the premises (eg dwelling, shop, farm, hotel etc):

Does the claimant occupy the premises Yes/No (delete as applicable) If yes, does the claimant occupy the whole or part only of the premises Whole/Part (delete as applicable) If claimant occupies only part of premises please give details:

Details of the claimant's interest ie. owner, mortgager, trustee, tenant with more than three years of lease to run etc: Date acquired: Manner in which acquired (purchase, inheritance etc): If the interest is subject to mortgage, the name and address (including Postcode) of mortgagee and mortgagee's roll/reference number. If more than one mortgagee, please indicate the order of priority. If none please state None. Names and addresses of other persons having an interest in the land together with details of their interest (ie freeholder, tenant etc). If none please state None.

Amount of compensation being applied for:

Does the claimant have an interest (eg freehold or tenancy etc) in any other land adjacent to the land in respect of which the claim is made: Yes/No (delete as applicable) If Yes please give details including the date when the interest was acquired

Where appropriate, give the name, address and telephone number of the professional adviser(s) acting on behalf of the claimant. If none please state None:

Claimant 1

Signed:	Date:

Claimant 2

Signed:	Date:

Other Claimants

Signed:	Date:

Signed:	Date:

Signed:	Date:

Signed:	Date:

If signing on behalf of claimant please specify reason