Federal Free Printable Form 3911 (Rev. 4-2009) for 2017 Federal Taxpayer Statement Regarding Refund

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Taxpayer Statement Regarding Refund
Form 3911 (Rev. 4-2009)

Department of the Treasury – Internal Revenue Service Form 3911 (Rev. April 2009) OMB NO. 1545-1384 Taxpayer Statement Regarding Refund The box checked below is in reply to your inquiry on about your Federal tax return for , $ We sent you the following refund(s) $ Check Direct Deposit on , $ . The U.S. Postal Service returned your check because they could not deliver it. Your check was not cashed within one year of the issue date as the law requires and it can no longer be cashed. If we indicated above that your check was returned by the Post Office or not cashed within one year of the issue date, please complete Sections I and III of this form and send it back to us in the enclosed envelope or facsimile form to . We will send you a new check within six weeks of the date we receive this form. If you did not receive the refund check, or if you received it and it was lost, stolen or destroyed, please complete Sections I, II and . Ill. Send this form back to us in the enclosed envelope or facsimile form to . If you don’t hear from us by six weeks from the date you send the form back to us, please contact us at If you prefer, you may write to us at the service center where you filed your return. Section I Print your current name(s), taxpayer identification number (for individuals, this is your social security number, for businesses, it is your employer identification number) and address, including ZIP code. If you filed a joint return, show the names of both husband and wife on lines 1 and 2 below. 1. Your name Taxpayer Identification Number 2. Spouse’s name (if a name is entered here, spouse must sign on line 14). Taxpayer Identification Number 3. Street Apt. No. City State Area code Please give us a phone number where you can be reached between 8 a.m. and 4 p.m. Include area code. Zip code Number If any of the above has changed since you filed your tax return, please enter the information below exactly as shown on your return. 4. Name(s) Taxpayer Identification Number(s) Street Apt. No. City State Zip code If you have filed a power of attorney authorizing a representative to receive your refund check, please enter his or her name and mailing address below. 5. Name of representative 7. Type of return: 6. Address (include ZIP code) Individual Type of refund requested: Business, Form Check Tax period: Other Direct Deposit Amount: $ Date filed: Refund Information Section II (Please check all boxes that apply to you.) I received a refund check, but it was lost, stolen or destroyed. 8. I didn’t receive a refund. 9. I received the refund check and signed it. NOTE: The law doesn’t allow us to issue a replacement check if you endorsed it and someone other than you cashed the check, since that person didn’t forge your signature. 10. I have received correspondence about the tax return. (Please attach a copy if possible.) (Please give us the following information if possible.) 11. Name of bank and account number where you normally cash or deposit your checks: Bank: Account number: YES 12. a. If the refund was a direct deposit, did you receive a “Refund Anticipation Loan”? b. Enter the Routing Transit Number(s) , Catalog Number 41167W , , , NO , and account number(s) shown on your return for the refund you did not receive. (Continued on back) Form 3911 (Rev. 4-2009) Certification Section III Please sign below, exactly as you signed the return. If this refund was from a joint return, we need the signatures of both husband and wife before we can trace it. Under penalties of perjury, I declare that I have examined this form, and to the best of my knowledge and belief, the information is true, correct, and complete. I request that you send a replacement refund, and if I receive two refunds I will return one. 13. Signature (For business returns, signature of person authorized to sign the check) 14. Spouse’s signature, if required (For businesses, enter the title of the person who signed above.) Date: Date: Description of Check Section IV (For Internal Revenue Service use only) Schedule number Refund Date Amount Other (DLN, Check/Symbol, etc.) Schedule number Refund Date Amount Other (DLN, Check/Symbol, etc.) Schedule number Refund Date Amount Other (DLN, Check/Symbol, etc.) Paperwork Reduction Act Notice – We ask for the information on this form to carry out the Internal Revenue laws of the United States. You aren’t required to give us the information since the refund you claimed has already been issued. However, without the information we won’t be able to trace your refund, and may be unable to replace it. You may give us the information we need in a letter. The time needed to complete this form will vary depending on individual circumstances. The estimated average time is less than 5 minutes. If you have comments concerning the accuracy of this time estimate or suggestions for making this form more simple, we would be happy to hear from you. You can write to the Internal Revenue Service, Attention: Tax Products Coordinating Committee, Western Area Distribution Center, Rancho Cordova, CA 95743-0001. DO NOT send this form to this office. Instead, use the envelope provided, or mail it to the Internal Revenue Service center where you would normally file a paper tax return. Form 3911 (Rev. 4-2009)
Extracted from PDF file 2016-federal-form-3911.pdf, last modified September 2008

More about the Federal Form 3911 Individual Income Tax TY 2016

We last updated the Taxpayer Statement Regarding Refund in January 2017, so this is the latest version of Form 3911, fully updated for tax year 2016. You can download or print current or past-year PDFs of Form 3911 directly from TaxFormFinder. You can print other Federal tax forms here.


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Other Federal Individual Income Tax Forms:

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Form Sources:

The Internal Revenue Service usually releases income tax forms for the current tax year between October and January, although changes to some forms can come even later. We last updated Federal Form 3911 from the Internal Revenue Service in January 2017.

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About the Individual Income Tax

The IRS and most states collect a personal income tax, which is paid throughout the year via tax withholding or estimated income tax payments.

Most taxpayers are required to file a yearly income tax return in April to both the Internal Revenue Service and their state's revenue department, which will result in either a tax refund of excess withheld income or a tax payment if the withholding does not cover the taxpayer's entire liability. Every taxpayer's situation is different - please consult a CPA or licensed tax preparer to ensure that you are filing the correct tax forms!

Historical Past-Year Versions of Federal Form 3911

We have a total of four past-year versions of Form 3911 in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:


2016 Form 3911

Form 3911 (Rev. 4-2009)

Taxpayer Statement Regarding Refund 2015 Form 3911

Form 3911 (Rev. 4-2009)

Taxpayer Statement Regarding Refund 2012 Form 3911

Form 3911 (Rev. 4-2009)

Taxpayer Statement Regarding Refund 2011 Form 3911

Form 3911 (Rev. 4-2009)


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