Catalog Number 41167W www.irs.gov
Form
3911 (Rev. 10-2022)
Form 3911
(October 2022)
Department of the Treasury - Internal Revenue Service
Taxpayer Statement Regarding Refund
OMB Number
1545-1384
The information below is in reply to your inquiry on about your Federal tax refund for
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
.
Note: You must complete a separate Form 3911 for each refund for which you are requesting information.
Note: If you are in possession of a check which was not cashed within one year of the issue date as the law requires, it can no longer
be cashed, contact the service for instructions on how to return your check.
For information on how to complete or where to send this form, visit www.irs.gov/forms-pubs/about-form-3911-taxpayer-statement-
regarding-refund.
Section I
Print your current name(s), taxpayer identification number (for individuals, this may be your social security
number or your ITIN, 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 Taxpayer Identification Number
2. Spouse’s name (if a name is entered here, spouse must sign on line 11) Taxpayer Identification Number
3. Current address Apt. No. City State ZIP code
Give us a phone number where you can be reached between
8 a.m. and 4 p.m. Include area code.
Area code Telephone number
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)
Address on return if different from current address Apt. No. City State ZIP code
If you authorized a representative to receive your refund check, 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
Type of refund requested Check Direct Deposit
Refund amount $
Name of bank (where you normally cash or deposit your checks)
Account type Checking Saving Other
Bank RTN Account number
Tax period
Date filed
Section II Refund Information (check all boxes that apply to you)
8. I didn’t receive a refund. I received a refund check, but it was Lost Stolen 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.
Section III Certification
Sign below. If this refund was from a joint return, both spouses must sign, before we can begin a trace.
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) Date
11. Spouse’s signature, if required (for businesses, enter the title of the person who signed above) Date