Information Collection

Taxpayer Statement Regarding Refund

IC 18226 under ICR 201311-1545-001 · OMB 1545-1384.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.