Charitiable Giving Request

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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.

Requestor

* Name Enter Requestor's Name. Required.

* Phone Number Enter Valid Phone Number. Required.

* Email Enter Valid Email Address. Required.

Organization

* Name Enter Organization Name. Required.

* Website Enter a Valid URL. Required.

* Mission

Request Details

* Charitable Item/Event/Initiative Enter Charitable Item/Event/Initiative. Required.

* Community Impact Area
Select Community Impact Area. Required.

* Date Funds are Needed

* Amount Requested Enter Amount Requested. Required.

* Physical Address Enter Physical Address. Required.

* Mailing Address Enter Mailing Address. Required.

CVR Employee Sponsor

* Additional Info/Items Needed & When (Logos, Ads, Banners):

Document

* Current W-9 Document

(Only PDF or PNG file formats allowed.)

Supporting Document (optional)

(Only PDF or PNG file formats allowed.)

Supporting Document (optional)

(Only PDF or PNG file formats allowed.)