Form 3911, Taxpayer Statement Regarding Refund Instructions
This form contains 49 fields organized into 11 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Address Information | ||
| 3. Current address | Text |
Enter your current street address.
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| 3. Apartment number | Text |
Enter your apartment number if applicable.
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| 3. City | Text |
Enter the city of your current address.
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| 3. State | Text |
Enter the state of your current address. Use the two-letter state abbreviation.
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| 3. ZIP code | Text |
Enter the ZIP code of your current address.
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| Bank Information | ||
| Name of bank (where you normally cash or deposit your checks) | Text |
Enter the name of the bank where you usually cash or deposit your checks.
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| Account type. Checking | CheckBox |
Check this box if your account type is Checking.
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| Saving | CheckBox |
Check this box if your account type is Saving.
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| Bank R T N | Text |
Enter the Bank Routing Transit Number (RTN).
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| Account number | Text |
Enter your bank account number.
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| Certification | ||
| Section 3. Certification. 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. 10. Signature (for business returns, signature of person authorized to sign the check) | Text |
This field is for the primary taxpayer's signature. By signing, you certify under penalties of perjury that the information provided is true, correct, and complete. If you receive two refunds, you agree to return one.
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| Date | Text |
Enter the date when the primary taxpayer signed the form.
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| 11. Spouse’s signature, if required (for businesses, enter the title of the person who signed above) | Text |
This field is for the spouse's signature if required. For businesses, enter the title of the person who signed above.
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| Date | Text |
Enter the date when the spouse or authorized business representative signed the form.
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| Contact Information | ||
| Give us a phone number where you can be reached between 8 a.m. and 4 p.m. Include area code.. Area code | Text |
Enter the area code of the phone number where you can be reached between 8 a.m. and 4 p.m.
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| Telephone number | Text |
Enter the phone number where you can be reached between 8 a.m. and 4 p.m.
|
| Inquiry Information | ||
| Page 1. The information below is in reply to your inquiry on. Date | Text |
Enter the date when you received the inquiry about your federal tax refund.
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| Personal Information | ||
| Section 1. Print your current name(s), taxpayer identification number (for individuals, this may be your social security number or your I T I N, for businesses, it is your employer identification number) and address, including ZIP code. If you filed a joint return, enter the information of both spouses on lines 1 and 2 below. 1. Your name | Text |
Enter your current name. If you filed a joint return, enter the name of both spouses.
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| Taxpayer Identification Number | Text |
Enter your Taxpayer Identification Number (TIN). For individuals, this may be your Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN). For businesses, it is your Employer Identification Number (EIN).
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| 2. Spouse’s name (if a name is entered here, spouse must sign on line 11) | Text |
Enter your spouse's name if applicable. If a name is entered here, the spouse must sign on line 11.
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| Taxpayer Identification Number | Text |
Enter your spouse's Taxpayer Identification Number (TIN).
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| Enter the information on line 4 exactly as it appeared on your tax return, if no change from above, enter N/A in fields below. 4. Name(s) | Text |
Enter the name(s) exactly as it appeared on your tax return. If there is no change from the information provided above, enter 'N/A'.
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| 4. Address on return if different from current address | Text |
Enter the address that was on your tax return if it is different from your current address.
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| 4. Apartment number | Text |
Enter the apartment number that was on your tax return if it is different from your current address.
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| 4. City | Text |
Enter the city that was on your tax return if it is different from your current address.
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| 4. State | Text |
Enter the state abbreviation (2 characters) that was on your tax return if it is different from your current address.
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| 4. ZIP code | Text |
Enter the ZIP code that was on your tax return if it is different from your current address.
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| Refund Information | ||
| about your Federal tax refund for. Date | Text |
Enter the date related to your federal tax refund.
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| Type of refund requested. Check | CheckBox |
Check this box if you are requesting a refund by check.
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| Direct Deposit | CheckBox |
Check this box if you are requesting a refund by direct deposit.
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| Refund amount | Text |
Enter the amount of the refund you are inquiring about.
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| Section 2. Refund Information (check all boxes that apply to you). 8. I didn’t receive a refund | CheckBox |
Check this box if you did not receive a refund.
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| 8. I received a refund check, but it was lost, stolen or destroyed | CheckBox |
Check this box if you received a refund check, but it was lost, stolen, or destroyed.
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| 8. Lost | CheckBox |
Check this box if your refund check was lost.
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| 8. Stolen | CheckBox |
Check this box if your refund check was stolen.
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| 8. Destroyed | CheckBox |
Check this box if your refund check was destroyed.
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| 9. I received the refund check and signed it | CheckBox |
Check this box if you received the refund check and signed it.
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| Representative Information | ||
| If you authorized a representative to receive your refund check, enter his or her name and mailing address below. 5. Name of representative | Text |
If you authorized a representative to receive your refund check, enter their name and mailing address.
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| 6. Address (include ZIP code) | Text |
Enter the address of the representative, including the ZIP code.
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| Return Information | ||
| 7. Type of return. Individual | CheckBox |
Check this box if the type of return is Individual.
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| 7. Type of return. Business | CheckBox |
Check this box if the type of return is Business.
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| 7. Type of return. Form number | Text |
Enter the form number of the return (e.g., 1040, 1120).
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| 7. Type of return. Other | CheckBox |
Check this box if the type of return is Other.
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| 7. Type of return. If other, enter type of return | Text |
If you selected 'Other' for the type of return, enter the type of return here.
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| 7. Type of return. Other | CheckBox |
Check this box if the type of return is Other.
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| 7. Type of return. If other, enter type of return | Text |
If you selected 'Other' for the type of return, specify the type of return here.
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| Submission Information | ||
| If you did not receive your refund or if the refund check you received was lost, stolen or destroyed, complete the entire form. If there are portions of the form that do not apply to you, you may mark them as N/A. Return to us in the envelope provided or fax the form to | Text |
Provide the return address or fax number where the completed form should be sent.
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| Tax Information | ||
| Tax period | Text |
Specify the tax period for which you are inquiring about the refund.
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| Date filed | Text |
Enter the date when you filed your tax return.
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