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Yes! You can use AI to fill out DS 1891, Applicant/Vendor Disclosure Statement (State of California Department of Developmental Services)

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DS 1891, Applicant/Vendor Disclosure Statement (State of California Department of Developmental Services), page 1
Moderate · 58/100Form Complexity Index

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What this form asks for

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DS 1891 (Applicant/Vendor Disclosure Statement) is an official California Department of Developmental Services form required for applicants seeking vendorization with a regional center, or when requested by the vendoring regional center. It collects key compliance disclosures such as ownership/control interests (including managing employees), related-party relationships, subcontractor and significant business transaction information, and whether any involved individuals/entities are excluded under federal or state rules. The form is important because incomplete or inaccurate disclosure can lead to denial of enrollment or termination of vendorization, and the signer certifies the information under penalty of perjury and must report changes within 30 days.
Fillable fields111
Pages4
Sections29
Form Complexity IndexModerate, 58/100

The AI checks your answers before you download

16 checks built for this form, so a wrong date or a missing answer is caught before anyone else sees it.

Part 1A required identifying information completeness

Validates that Part 1A includes the applicant/vendor legal name (as reported to IRS), vendor number and service code (if already assigned/known), business address, and telephone number. These fields are the minimum identifiers needed to match the disclosure to the correct entity and to contact the applicant. If any required element is missing, the submission should be flagged as incomplete and rejected or routed for correction before processing.

Business telephone number format and plausibility

Checks that the telephone number includes an area code and conforms to a valid NANP format (e.g., 10 digits, allowing standard punctuation). This reduces failed contact attempts and prevents invalid characters from entering downstream systems. If the phone number fails validation, the form should be returned for correction and not treated as a valid contact method.

Entity type selection is single-choice and present

Ensures exactly one entity type checkbox is selected in Part 1E (e.g., Parent/Consumer, Sole Proprietor, Partnership types, LLC, Governmental, Corporation, Nonprofit variants). The entity type drives which identifiers and ownership disclosures are expected and how the vendor is classified. If none or multiple boxes are checked, the submission should be rejected for clarification because subsequent sections cannot be validated reliably.

Conditional workflow: Parent/Consumer selection enforces required sections

If 'Parent or Consumer for Vouchers, Participant-Directed Services, or Purchase Reimbursements' is selected, validates that the applicant completed Part 1 and Part 3 and provided the Applicant/Vendor Signature and Date, and that Parts 2 and 4 are not required. This prevents unnecessary ownership/subcontractor disclosures for this category while still capturing exclusion information. If the required sections are missing (or if the wrong sections are submitted in lieu of required ones), the packet should be marked incomplete.

SSN format validation (where provided/required)

Validates that any Social Security Number entered (for the applicant/vendor in Part 1D or individuals listed in Parts 2/4) is exactly 9 digits and formatted consistently (e.g., XXX-XX-XXXX or digits-only), and is not an obvious invalid value (all zeros, repeated digits). Correct SSN formatting is critical for identity matching, tax reporting (where applicable), and exclusion screening. If invalid, the system should block submission or require correction, and should not attempt automated matching with malformed SSNs.

Date of Birth (DOB) format and reasonableness

Checks that any DOB provided uses a valid date format and represents a real calendar date, and that it is plausible (e.g., not in the future and not unreasonably old/young for an owner/managing employee). DOB is used for identity resolution and screening against exclusion lists. If DOB fails validation, the record should be flagged for correction and excluded from automated screening until fixed.

And 10 more checks
  • EIN format validation and mutual exclusivity with SSN for entity context
  • NPI format validation (if provided)
  • Secretary of State registration name required for registered entities
  • Corporation and LLC formation details completeness
  • Part 2 applicability statement or complete ownership/managing employee listing
  • Ownership/control threshold logic for Part 2C and Part 4A (≥5%)
  • Relationship disclosure consistency (Part 2B references valid names)
  • Excluded Individuals/Entities section completion or explicit 'not applicable'
  • Subcontractor and significant business transaction disclosures completeness
  • Applicant/Vendor signature, title, and date presence and date validity

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How to Fill Out DS 1891 Online for Free in 2026

What the AI walks you through.

  1. Enter Part 1 identifying information: legal name as reported to the IRS, vendor number/service code (if applicable), business address, phone number, Secretary of State registered name (if any), NPI (if any), and SSN/DOB and/or EIN.
  2. Select the correct entity type in Part 1(E) (e.g., sole proprietor, partnership, LLC with state of formation, corporation with corporate number/state, nonprofit type, governmental, or parent/consumer for vouchers/participant-directed services).
  3. Complete Part 2 ownership/control disclosures by listing all individuals/entities with direct or indirect ownership interests and/or managing employees (names, titles, addresses, SSNs, DOBs), and attach additional pages if needed.
  4. In Part 2(B) and 2(C), disclose family relationships among listed persons (spouse/parent/child/sibling) and identify any other vendors/providers where an owner/controller also holds at least a 5% interest (including vendor number/service code and SSN/NPI/EIN).
  5. Complete Part 3 by listing any excluded individuals or entities connected to the applicant/vendor (or indicate not applicable), using the definitions provided (e.g., OIG exclusions, Medi-Cal suspended/ineligible list, or qualifying convictions/settlements).
  6. Complete Part 4 subcontractor disclosures (or indicate not applicable): list ownership/control interests in subcontractors where the applicant/vendor has 5%+ direct/indirect ownership (include percentage), and list subcontractors/wholly owned suppliers with significant business transactions within the last 5 years.
  7. Review for accuracy and currency, make any corrections by lining through/initialing (no correction fluid), then sign and date the Applicant/Vendor Signature section as the applicant or authorized representative and submit with the full vendorization application packet to the appropriate regional center.

Common Mistakes in Completing DS 1891

The ones the AI is built to catch.

Using a business name that doesn’t match IRS or license records
Applicants often enter a “doing business as” name in Part 1A or Part 1B that doesn’t exactly match the legal name on IRS records, the California Secretary of State registration, or the facility/license name. This creates verification problems and can delay or derail vendorization because the regional center cannot match the entity across systems. To avoid this, use the exact legal name as reported to the IRS in Part 1A and the exact Secretary of State registered name in Part 1B (if applicable), and ensure it matches any licensing documentation.
Leaving Vendor Number/Service Code blank or entering the wrong identifiers
People frequently skip the Vendor Number and Service Code field because they assume it’s only for existing vendors, or they enter an internal tracking number instead. Missing or incorrect identifiers can cause misrouting, duplicate records, or delays in processing the application packet. If you already have a vendor number/service code, enter it exactly as issued; if you are a new applicant and truly do not have one, clearly mark “N/A” rather than leaving it blank.
Incorrect EIN format or mixing up EIN and SSN
A common error is entering an EIN without the required format (XX-XXXXXXX), transposing digits, or putting an SSN in the EIN field (or vice versa). This can trigger tax reporting and identity verification issues and may result in requests for correction or denial for incomplete/incorrect information. Double-check the IRS-issued EIN, use the required hyphenated format, and only provide SSN/DOB where the form requests it for the appropriate person/entity.
Not selecting exactly one entity type (or selecting the wrong structure)
Applicants often check multiple boxes in Part 1E or choose an entity type that doesn’t match their legal formation (e.g., checking “Sole Proprietor” when they are an LLC, or omitting the state of formation/incorporation). This mismatch can conflict with Secretary of State records and ownership disclosure requirements, leading to follow-up requests and processing delays. Select only one box, and complete the related details (state of formation, corporate number, state incorporated) exactly as shown on official filings.
Omitting required ownership/managing employee details in Part 2A
Many submissions list only the primary contact and fail to include all individuals/entities with direct or indirect ownership interests (5% or more), officers/directors (for corporations), partners (for partnerships), and managing employees as defined in the instructions. Incomplete disclosure is a major compliance issue and can result in denial of enrollment or later termination of vendorization. Use the definitions provided, list every applicable person with name, title, address, SSN, and DOB, and attach additional pages when needed rather than compressing or skipping entries.
Misunderstanding the 5% threshold and indirect ownership rules
People commonly assume only majority owners must be disclosed, or they ignore indirect ownership (ownership through another entity) and mortgage/debt interests that meet the 5% criteria. This leads to under-reporting of “persons with an ownership or control interest,” which is specifically required under 42 CFR 455.101 and Title 17. To avoid this, calculate both direct and indirect ownership percentages, include combined interests, and disclose any qualifying secured obligations that meet the 5% of property/assets test.
Failing to list family relationships among disclosed persons (Part 2B)
Applicants often leave Part 2B blank because they think it is optional or only applies to spouses, overlooking parent/child/sibling relationships among owners, officers, directors, or managing employees. Missing relationship disclosures can raise red flags during review and prompt additional documentation requests. Review everyone listed in Part 2A (and any relevant later sections) and explicitly list all qualifying relationships with names, relationship type, and addresses.
Not disclosing other related provider interests in Part 2C
A frequent mistake is answering Part 2C incompletely by listing only the applicant entity and not other vendors/providers where an owner/controller also holds 5% or more. This can cause compliance issues because the form specifically asks about cross-ownership (e.g., Medicare/Medicaid facilities or other vendors). To avoid this, identify every other applicant/vendor entity where any person with ownership/control in your organization also has at least a 5% interest, and provide the requested identifiers (vendor number/service code, SSN/NPI/EIN).
Marking “not applicable” for Excluded Individuals/Entities without checking or disclosing
Some applicants assume exclusions only apply to the organization itself and fail to consider owners, board members, officers, agents, or managing employees within the last ten years, or they do not check OIG/DHCS lists. Non-disclosure can lead to denial, termination, and potential legal consequences because the signature certifies truth under penalty of perjury. To avoid this, screen relevant individuals/entities against the OIG LEIE and DHCS Medi-Cal lists and disclose any applicable names, titles, and addresses in Part 3.
Incomplete subcontractor and significant business transaction reporting (Part 4A/4B)
Applicants often omit subcontractors/wholly owned suppliers or misunderstand what counts as a “significant business transaction” within the last five years, especially when services are delegated informally. Missing subcontractor ownership/control details can delay approval and may be treated as incomplete disclosure if later discovered. Keep a list of subcontractors and suppliers, identify any where you have 5% or more direct/indirect ownership (include percentage), and report significant transactions as defined (exceeding the lesser of $25,000 or 5% of operating expenses).
Improper corrections, illegible entries, or missing attachments/references
People frequently use correction fluid, overwrite fields, submit hard-to-read handwriting, or attach extra pages without referencing the specific part/question, making the packet difficult to audit. This can result in the form being returned for correction or delays while staff seek clarification. Follow the instructions: type or print clearly in ink, line through errors and initial/date corrections, and label any attachments with the exact Part and question number they supplement.
Missing signature, date, or authorized representative details (certification section)
A common final-step error is forgetting to sign/date, leaving the title blank, or having someone sign who is not an authorized representative for the entity. Because the form is a certification under penalty of perjury, an incomplete or unauthorized signature can invalidate the submission and halt processing. Ensure the signer is authorized (e.g., owner, officer, or designated representative), print the name and title, sign, and date the form, and be prepared to update the regional center within 30 days of any changes.

Frequently Asked Questions About DS 1891

 

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What happens to my information?
It is encrypted in transit and at rest, and it is never used to train AI.
How complex is DS 1891 to fill out?
DS 1891 has a Form Complexity Index of 58 out of 100, in the moderate tier: 111 fillable fields across 4 pages. Instafill.ai's AI fills it in under a minute, with every field there for you to review before you download.
What is the DS 1891 Applicant/Vendor Disclosure Statement used for?
It is used by the California Department of Developmental Services and regional centers to collect required ownership, control, subcontractor, and exclusion information as part of a vendorization application or when a regional center requests an updated disclosure.
Who must complete and submit this form?
Every applicant or vendor seeking vendorization (or already vendored when requested) must complete and submit a current DS 1891 as part of the application packet or upon request of the vendoring regional center.
I am a parent/consumer using Vouchers, Participant-Directed Services, or Purchase Reimbursements—what parts do I complete?
Complete Part 1 (page 2) and Part 3 (page 3), then go to the Applicant/Vendor Signature section (page 4) to sign and date.
Where do I submit the completed DS 1891?
Return the completed disclosure statement with your complete application package to the regional center to which you are applying.
Do I need to answer every question even if it does not apply to me?
Yes—answer all applicable questions, and for sections that do not apply, indicate that they are not applicable (the form notes this for Parts 2, 3, and 4).
What identifying information is required in Part 1?
Part 1 asks for the applicant/vendor name as reported to the IRS, vendor number and service code (if any), business address, phone number, any California Secretary of State registered name, NPI (if any), and SSN/DOB and/or EIN (if any), plus your entity type.
What if I do not have an NPI or an EIN?
The form says to provide the NPI or EIN “if any,” so you should leave it blank or mark as not applicable if you do not have one, while still completing the rest of the required fields.
How do I enter my EIN on the form?
Enter the nine-digit EIN in the format XX-XXXXXXX, as instructed in Part 1(D).
How do I choose the correct entity type in Part 1(E)?
Check only one box that best matches your organization’s structure (e.g., sole proprietor, partnership type, LLC with state of formation, corporation with corporate number and state, nonprofit type, governmental, or parent/consumer category).
Who must be listed in Part 2 (Ownership and Control Interests)?
List individuals/entities with direct or indirect ownership interests and/or managing employees, and include officers/directors (for corporations), partners (for partnerships), and anyone meeting the 5% ownership/control thresholds described in the definitions.
What does the 5% ownership/control threshold mean for reporting?
If a person or entity has 5% or more ownership (direct, indirect, or combined), or certain secured interests meeting the 5% value test, they are considered a person with an ownership or control interest and must be disclosed as applicable.
What relationships must be disclosed in Part 2(B)?
You must list people named in Part 2(A) (or Part 4(A)) who are related to each other as spouse, parent, child, or sibling, along with the relationship and address.
What is an “Excluded Individual or Entity,” and what do I do if someone involved is excluded?
Excluded individuals/entities include those on the OIG exclusion list, the DHCS Medi-Cal Suspended and Ineligible Provider List, or those meeting the Title 17 criteria (e.g., certain fraud/abuse convictions or settlements within the last 10 years). If applicable, list the person’s name, title, and address in Part 3.
When do I need to complete Part 4 about subcontractors and wholly owned suppliers?
Complete Part 4 if you have subcontractors or wholly owned suppliers that meet the criteria described, including ownership/control interests of 5% or more in subcontractors and significant business transactions within the last 5 years.
What happens if I make a mistake or need to correct something on the form?
Do not use correction fluid; instead, line through the error, then date and initial the correction in ink, and make sure all information is current as of the date you complete the form.
What are the consequences of not fully disclosing information or providing inaccurate information?
The form states that failure to disclose complete and accurate information may result in denial of enrollment/vendorization and/or termination of vendorization.
Do I have to update the regional center if information changes after I submit the form?
Yes—by signing, you agree to inform the vendoring regional center in writing within 30 days of any changes or if additional information becomes available.
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