Form Ct-3911 - Taxpayer Statement Regarding State Of Connecticut Tax Refund printable pdf download

Department of Revenue Services

Form CT-3911

State of Connecticut

Taxpayer Statement Regarding State of Connecticut Tax Refund

(Rev. 12/15)

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 the

only) or 860-297-5962 (from anywhere).

Department of Revenue Services (DRS) concerning this

Where to File

refund to Form CT-3911.

Mail to: Department of Revenue Services

DRS will provide information concerning your refund in writing.

Revenue Accounting Unit

If DRS determines that your refund check was cashed, a copy

PO Box 5035

of the cashed check will be mailed to you. If DRS determines

Hartford CT 06102-5035

that your refund check was not cashed, a stop payment will

be placed on the original check and a replacement check will

Fax to: 860-297-4757

be mailed to you.

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.

Form Ct-3911 - Taxpayer Statement Regarding State Of Connecticut Tax Refund

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