Form 3911
(Rev. April 2009)
Catalog Number 41167W
Taxpayer Statement Regarding Refund
Department of the Treasury – Internal Revenue Service OMB NO. 1545-1384
The box checked below is in reply to your inquiry on about your Federal tax return for
We sent you the following refund(s) $ , $ , $ on .
Check Direct Deposit
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 Zip code
Please give us a phone number where you can be reached
between 8 a.m. and 4 p.m. Include area code.
Area 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 6. Address (include ZIP code)
7. Type of return: Individual Business, Form Other Tax period:
Type of refund requested: Check Direct Deposit Amount: $ Date filed:
Section II Refund Information
(Please check all boxes that apply to you.)
8. I didn’t receive a refund. I received a refund check, but it was lost, stolen or destroyed.
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:
12. a. If the refund was a direct deposit, did you receive a “Refund Anticipation Loan”? YES NO
b. Enter the Routing Transit Number(s) , , , and account number(s)
, , shown on your return for the refund you did not receive.
(Continued on back) Form 3911 (Rev. 4-2009)
