0420 Form 15250 (PDF)

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f15250.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

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(April 2020)

[Name]

[Address]

[City, State, ZIP Code]

Section I

Department of the Treasury - Internal Revenue Service

EIN:

[EIN]

Provide your organization’s current status as a nonbank trustee or custodian:

1. The organization named above continues to exist and serve as a nonbank trustee or custodian

2. The organization named above no longer wants to serve as a nonbank trustee or custodian, and hereby notifies the IRS that it wishes to withdraw its Notice of Approval, effective immediately

3. The organization named above no longer exists

Section II

If the above organization’s name, address or employer identification number has changed since the Notice of Approval was issued to this entity or is different from the information shown on our published list,

[Name]

[Address]

[City, State, ZIP Code]

then complete the following:

4. The entity is notifying the IRS of a change to ensure the continuing accuracy of the representations made in its application

Name, address, employer identification number as shown on the Notice of Approval or on the IRS published list:

Section III

Correct name, address, employer identification number:

Signature Date

Printed name/title Telephone number

Catalog Number 74037Z www.irs.gov Form 15250 (4-2020)