Connecticut Taxpayer Statement Regarding State of Connecticut Tax Refund

Taxpayer Statement Regarding State of Connecticut Tax Refund
Form CT-3911
Department of Revenue Services
State of Connecticut
(Rev. 12/23)

Form CT-3911

Taxpayer Statement Regarding State of Connecticut Tax Refund
File Form CT-3911 using myconneCT at portal.ct.gov/DRS-myconneCT.

Purpose: Use Form CT-3911 to report a missing or stolen Connecticut tax refund that was a direct deposit or issued as a check.
Attach copies of any correspondence received from DRS
concerning this refund to Form CT-3911.
The Department of Revenue Services (DRS) will provide information
in writing concerning your refund. If DRS determines that your refund
check was cashed, a copy of the cashed check will be mailed to
you. If DRS determines that your refund check was not cashed, a
stop payment will be placed on the original check and a replacement
check will be mailed to you.

If you do not receive any information from DRS within six weeks after
filing Form CT-3911, call DRS Monday through Friday, 8:30 a.m. to
4:30 p.m. at 800-382-9463 (Connecticut calls outside the Greater
Hartford calling area only) or 860-297-5962 (from anywhere).

Part 1	 Refund Information
Prior to completing Part 1, verify with your bank that the refund has not been deposited.
1.	 Type of return filed: 	  Individual	  Business	  Other____________________________________
	 Form:_____________________ 	 Tax period:__________________ 	 Date filed:______________________________
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:	

Part 2	



Never received; or	



Lost, stolen or destroyed.

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 Lines 1, 2, and 3.
1. Your name (or business name)	

Enter your TIN and check the appropriate box.

2. Spouse’s name (if joint return)	

Spouse’s SSN

 SSN
 CT Reg. No.
 FEIN

••
••
___ ___ ___ •• ___ ___ •• ___ ___ ___ ___

3. Address (number and street)	

Part 3	

Apt. no.	

PO Box	

City	

State	

ZIP Code	

Home/cell telephone number

–

–

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 DRS is a fine of not more than $5,000,
or imprisonment for not more than five years, or both.

Please
sign
here.

Your signature	

Title (if business return)	

Date

Spouse’s signature (if joint return)	

	

Date

Visit us at portal.ct.gov/DRS for more information.