Taxpayer Statement Regarding Refund

Form 3911--Taxpayer Statement Regarding Refund

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-1384 can be found here:

Documents and Forms

Document Name Document Type
Form 3911 Taxpayer Statement Regarding Refund Form and Instruction
3911 Taxpayer Statement Regarding Refund Form-3911.pdf Form and Instruction
REV_PA & PRA Statement_Form_3911_MAY2014.docx Revised Privacy Act & PRA Statement IC Document

Information Collection (IC) Details

IC Title:	Taxpayer Statement Regarding Refund	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3911	Taxpayer Statement Regarding Refund	Form-3911.pdf		No		Fillable Printable

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	200,000	200,000
Annual IC Time Burden (Hours)	16,600	16,600
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Revised Privacy Act & PRA Statement	REV_PA & PRA Statement_Form_3911_MAY2014.docx	05/29/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.