This form must be completed in its entirety to request a charitable donation from CVR Energy, Inc. and its subsidiaries (collectively, "CVR"). CVR only accepts requests from non-profit 501 (c)(3) organizations that specifically relate to one or more of our five community impact areas: Youth, Education, Health & Human Services, Environment and Culture.

Please submit this form along with a current W-9 PDF document. Please note that charitable giving requests are processed on a quarterly basis and require no less than 60 days’ notice. For more information, please email CorporateAffairs@CVREnergy.com.