Form 3911 - Taxpayer Statement Regarding Refund Page 2
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1
2Certification
Section III
Please sign below, exactly as you signed the return. If this refund was from a joint return, we need the signatures of both
husband and wife before we can trace it.
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.
13. Signature (For business returns, signature of person authorized to sign the check)
Date:
14. Spouse’s signature, if required (For businesses, enter the title of the person who signed above.)
Date:
Description of Check
Section IV
(For Internal Revenue Service use only)
Schedule number
Refund Date
Amount
Other (DLN, Check/Symbol, etc.)
Schedule number
Refund Date
Amount
Other (DLN, Check/Symbol, etc.)
Schedule number
Refund Date
Amount
Other (DLN, Check/Symbol, etc.)
Paperwork Reduction Act Notice – We ask for the information on this form to carry out the Internal
Revenue laws of the United States. You aren’t required to give us the information since the refund you
claimed has already been issued. However, without the information we won’t be able to trace your
refund, and may be unable to replace it. You may give us the information we need in a letter.
The time needed to complete this form will vary depending on individual circumstances. The estimated
average time is less than 5 minutes.
If you have comments concerning the accuracy of this time estimate or suggestions for making this form
more simple, we would be happy to hear from you. You can write to the Internal Revenue Service,
Attention: Tax Products Coordinating Committee, Western Area Distribution Center, Rancho Cordova,
CA 95743-0001.
DO NOT send this form to this office. Instead, use the envelope provided, or mail it to the Internal
Revenue Service center where you would normally file a paper tax return.
3911
Form
(Rev. 4-2009)
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