Form Ct-3911 - Taxpayer Statement Regarding State Of Connecticut Tax Refund - Connecticut Department Of Revenue
ADVERTISEMENT
1Department of Revenue Services
Form CT-3911
State of Connecticut
(Rev. 12/13)
Taxpayer Statement Regarding State of Connecticut Tax Refund
Use Form CT-3911 to report a missing or stolen Connecticut tax refund that was a direct deposit or issued as a check.
Do not use this form to report a missing debit card. Contact Chase Customer Service at 866-586-1705 to report lost,
stolen, not received, or damaged debit cards and to request a new card(s).
General Instructions
If you do not receive any information from DRS within six
weeks after fi ling Form CT-3911, contact DRS at 800-382-9463
Complete this form in blue or black ink only.
(Connecticut calls outside the Greater Hartford calling area
Attach copies of any correspondence received from
only) or 860-297-5962 (from anywhere).
DRS concerning this refund to Form CT-3911.
Where to File
DRS will provide information concerning your refund in writing.
Mail to: Department of Revenue Services
If DRS determines that your refund check was cashed, a copy
Revenue Accounting Unit
of the cashed check will be mailed to you. If DRS determines
PO Box 5035
that your refund check was not cashed, a stop payment will
Hartford CT 06102-5035
be placed on the original check and a replacement check will
be mailed to you.
Fax to: 860-297-4757
Part I
Refund Information
Prior to completing Part I, verify with your bank that the refund has not been deposited.
1. Type of return fi led:
___________________________________
Individual
Business
Other
Form: ____________________
Tax period: _________________
Date fi led: _____________________________
2. Type of refund requested:
Direct Deposit
Check
If Direct Deposit, enter your bank information:
Bank name: __________________________________________
Account #: ____________________________
If Check, identify if the refund check was:
Never received; or
Lost, stolen or destroyed.
Part II
Taxpayer Information
Print your name, Taxpayer Identifi cation Number (TIN), and mailing address. For individuals, the TIN is your Social Security Number (SSN);
for businesses, the TIN is your Connecticut Tax Registration Number or Federal Employer Identifi cation Number (FEIN). Check the box
to indicate which TIN you are listing. If you fi led a joint return, you must complete Lines 1, 2, and 3.
1. Your name (or business name)
Enter your TIN and check the appropriate box.
SSN
CT Reg. No.
FEIN
2. Spouse’s name (if joint return)
Spouse’s SSN
• •
• •
• •
• •
___ ___ ___
___ ___
___ ___ ___ ___
3. Address (number and street)
Apt. no.
PO Box
City
State
ZIP Code
Home/cell telephone number
(
)
Part III
Signature
Sign below exactly as you signed the original return. For a joint return, both you and your spouse must sign. 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 fi ne of not more than $5,000, or imprisonment for not more than fi ve years, or both.
Your signature
Title (if business return)
Date
Please
sign
Spouse’s signature (if joint return)
Date
here.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial