Continued on back Form 3911 Rev. 4-2009 Certification 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. Department of the Treasury Internal Revenue Service Form 3911 Rev. April 2009 OMB NO. 1545-1384 Taxpayer Statement Regarding Refund The box checked below is in reply to your inquiry on about your Federal tax return for We sent you the following refund s Check Direct Deposit on. The U*S* Postal Service returned your check because they could not deliver it. Your check was not cashed within one year of the issue date as the law requires and it can no longer be cashed* If we indicated above that your check was returned by the Post Office or not cashed within one year of the issue date please complete Sections I and III of this form and send it back to us in the enclosed envelope or facsimile form to We will send you a new check within six weeks of the date we receive this form* If you did not receive the refund check or if you received it and it was lost stolen or destroyed please complete Sections I II and Ill* Send this form back to us in the enclosed envelope or facsimile form to If you don t hear from us by six weeks from the date you send the form back to us please contact us at If you prefer you may write to us at the service center where you filed your return* Section I Print your current name s taxpayer identification number for individuals this is your social security number for businesses it is your employer identification number and address including ZIP code. If you filed a joint return show the names of both husband and wife 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 14. 3. Street Apt. No* City State Area code Please give us a phone number where you can be reached between 8 a*m* and 4 p*m* Include area code. Zip code Number If any of the above has changed since you filed your tax return please enter the information below exactly as shown on your return* 4. Name s If you have filed a power of attorney authorizing a representative to receive your refund check please enter his or her name and mailing address below. 5. Name of representative 7. Type of return 6. Address include ZIP code Individual Type of refund requested Business Form Tax period Other Amount Date filed Refund Information Please check all boxes that apply to you. I received a refund check but it was lost stolen or destroyed* I didn t receive a refund. 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. I have received correspondence about the tax return* Please attach a copy if possible. Name of bank and account number where you normally cash or deposit your checks Bank Account number YES 12. a* If the refund was a direct deposit did you receive a Refund Anticipation Loan b. Enter the Routing Transit Number s Catalog Number 41167W NO and account number s shown on your return for the refund you did not receive.
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