Department of the Treasury - Internal Revenue Service                           OMB Number 
   Form 3911                                                                                                             1545-1384
   (October 2022)         Taxpayer Statement Regarding Refund
The information below is in reply to your inquiry on                                   about your Federal tax refund for
If you did not receive your refund or if the refund check you received was lost, stolen or destroyed, complete the entire form. If there are 
portions of the form that do not apply to you, you may mark them as N/A. Return to us in the envelope provided or fax the form to
                                                                                                                                       .
Note: You must complete a separate Form 3911 for each refund for which you are requesting information.
Note: If you are in possession of a check which was not cashed within one year of the issue date as the law requires, it can no longer 
be cashed, contact the service for instructions on how to return your check.
For information on how to complete or where to send this form, visit www.irs.gov/forms-pubs/about-form-3911-taxpayer-statement-
regarding-refund.
                      Print your current name(s), taxpayer identification number (for individuals, this may be your social security 
Section I             number or your ITIN, for businesses, it is your employer identification number) and address, including ZIP code. 
                      If you filed a joint return, enter the information of both spouses on lines 1 and 2 below.
1. Your name                                                                                 Taxpayer Identification Number

2. Spouse’s name (if a name is entered here, spouse must sign on line 11)                    Taxpayer Identification Number

3. Current address                                      Apt. No.  City                                               State    ZIP code

Give us a phone number where you can be reached between           Area code                  Telephone number
8 a.m. and 4 p.m. Include area code.
Enter the information on line 4 exactly as it appeared on your tax return, if no change from above, enter N/A in fields below.
4. Name(s)

Address on return if different from current address     Apt. No.  City                                               State    ZIP code

If you authorized a representative to receive your refund check, enter his or her name and mailing address below.
5. Name of representative                                         6. Address (include ZIP code)

7. Type of return     Individual        Business,       Form                           Other                         Tax period
Type of refund requested                Check                Direct Deposit Refund amount   $
Name of bank (where you normally cash or deposit your checks)
                                                                                                                     Date filed
Account type          Checking          Saving               Other
Bank RTN                                                Account number
Section II                              Refund Information (check all boxes that apply to you)
8.   I didn’t receive a refund.         I received a refund check, but it was          Lost          Stolen     Destroyed
9.   I received the refund check and signed it. 
NOTE: The law doesn’t allow us to issue a replacement check if you endorsed it and someone other than you cashed the check, since 
that person didn’t forge your signature.

Section III                                                               Certification
Sign below. If this refund was from a joint return, both spouses must sign, before we can begin a trace.
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.
10. Signature (for business returns, signature of person authorized to sign the check)                               Date

11. Spouse’s signature, if required (for businesses, enter the title of the person who signed above)                 Date

Catalog Number 41167W                                        www.irs.gov                                        Form 3911 (Rev. 10-2022)

                                 Privacy Act and 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. 
We need the information to ensure that you are complying with these laws and to allow us to determine the correctness of your refund or the right 
amount of payment. Your Social Security Number and the other information are being requested in order that the Department of the Treasury can 
process your refund. The authority of requesting your social security number is 26 United States Code, section 6109. If you cannot or will not furnish the 
information, the tracing of your refund may be delayed. 
You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB 
control number. Books or record relating to a form or its instructions must be retained as long as their contents may become material in the 
administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Internal Revenue Code section 
6103. The time needed to compete and file 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 simpler, 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, please use the envelope provided or mail the form to the Internal Revenue Service center where you would 
normally file a paper tax return.

Catalog Number 41167W                                   www.irs.gov                                         Form 3911 (Rev. 10-2022)