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 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.