Form Ct-3911 - Taxpayer Statement Regarding State Of Connecticut Tax Refund
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1Form CT-3911
Department of Revenue Services
State of Connecticut
Taxpayer Statement Regarding State of Connecticut Tax Refund
(Rev. 12/07)
Complete in blue or black ink only.
Part I
Refund Information
Check all boxes that apply:
Q
Q
I did not receive a refund check.
I received a refund check, but it was lost, stolen, or destroyed.
Q
Q
I received a refund check and signed it.
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: __________________________
Part II
Taxpayer Information
Print your name, Taxpayer Identification 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 Identification Number (FEIN). Check
the box to indicate which TIN you are listing. 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)
Enter your TIN and check the appropriate box.
Q
Q
Q
__________________________
SSN
CT Reg. No.
FEIN
2. Spouse’s Name (if joint return)
__________________________
SSN
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 information above has changed since you filed your return, enter the information below exactly as shown on your return.
5. Your Name (or business name)
Enter your TIN and check the appropriate box.
Q
Q
Q
__________________________
SSN
CT Reg. No.
FEIN
6. Spouse’s Name (if joint return)
__________________________
SSN
7. Address (number and street)
PO Box
Apt. No.
City
State
ZIP Code
8. Name of individual making the request if different from above.
Relationship to above individual or title (if business return)
9. 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 DRS determines that your refund check was cashed, you will receive a copy of the cashed check. If DRS determines 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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