Form Ct-3911 - Taxpayer Statement Regarding Refund
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1RESET FORM
Form CT-3911
Department of Revenue Services
State of Connecticut
Taxpayer Statement Regarding Refund
(Rev. 12/06)
Part I
Refund Information
Check all boxes that apply:
Q
1.
I did not receive a refund check.
Q
2.
I received a refund check, but it was lost, stolen, or destroyed.
Q
3.
I received a refund check and signed it.
Q
4.
I received correspondence about the tax return. (Attach a copy if possible.)
Type of return filed:
Q
Q
Q
Individual, Form _________________
Business, Form ____________________
Other ___________________
Tax period: _______________________ Date filed: ___________________________
Taxpayer Information
Part II
Print your name, Taxpayer Identification Number (for individuals, this is your Social Security Number; for businesses, this is your
Connecticut Tax Registration Number), and mailing address. If you filed a joint return, you must complete Line 1 and Line 2. Any
reference in this document to a spouse also refers to a party to a civil union recognized under Connecticut law.
1. Your Name (or business name)
Taxpayer Identification Number
2. Spouse’s Name (if joint return)
Taxpayer Identification Number
3. Address (number and street)
PO Box
Apt. No.
City
State
ZIP Code
4. Telephone number where you can be reached between 8 a.m. and 5 p.m.
Daytime Telephone Number
(
)
If any of the above has changed since you filed your tax return, enter the information below exactly as shown on your return.
5. Name(s) (or business name)
Taxpayer Identification Number(s)
6. Address (number and street)
PO Box
Apt. No.
City
State
ZIP Code
7. Name of individual making the request if different from above.
Relationship to above individual or title (if business return)
8. Address (number and street)
PO Box
Apt. No.
City
State
ZIP Code
Part III
Signature
Please sign below exactly as you signed the return. For a joint return, both you and your spouse must sign this form.
For business returns, the signature must be of the person authorized to sign the check.
Declaration: I declare under penalty of law that I have examined this document and, to the best of my knowledge and belief, it is true,
complete, and correct. I understand the penalty for willfully delivering a false return or document to the Department of Revenue Services
(DRS) is a fine of not more than $5,000, or imprisonment for not more than five years, or both.
Your Signature
Title (if business return )
Date
Please
Sign
Spouse’s Signature (if joint return)
Date
Here
If it is determined that your refund check was cashed, you will receive a copy of the cashed check. If it is determined that your
refund check was not cashed, a stop payment will be placed on the original check and you will receive a replacement check. If you
do not receive either of the above within six weeks from filing this form, contact the Refund Unit at 860-297- 4845.
Part IV
Where to File
Mail to:
Department of Revenue Services
Refund Unit
PO Box 5035
Hartford CT 06102-5035
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