DS 1891, Applicant/Vendor Disclosure Statement (State of California Department of Developmental Services) Completed Form Examples and Samples
Explore comprehensive examples and samples of the California DS 1891, Applicant/Vendor Disclosure Statement. This page provides filled-out templates for various scenarios, helping new and existing vendors for the Department of Developmental Services (DDS) correctly complete the form. Find clear instructions and avoid common errors on your vendor application.
DS 1891 Example – New Sole Proprietor Vendor
How this form was filled:
This example shows a completed DS 1891 form for a new sole proprietor, 'Golden State Behavioral Services,' applying to become a vendor. It details the applicant's business information, specifies the associated regional center, and indicates 'No' to all disclosure questions, a common scenario for new applicants without prior adverse actions. The form is properly signed and dated for the year 2026.
Information used to fill out the document:
- Applicant/Vendor Name: Golden State Behavioral Services
- Applicant/Vendor Type: Sole Proprietorship
- Vendor Number: N/A - New Applicant
- Business Address: 456 Pacific Way, Suite 100, San Francisco, CA 94105
- Business Phone: 415-555-0123
- Contact Person: Dr. Jane Smith
- Contact Person Title: Owner / Clinical Director
- Associated Regional Center: Golden Gate Regional Center
- Disclosure Question 1 Answer (Sanction/Suspension): No
- Disclosure Question 2 Answer (License Revocation): No
- Disclosure Question 3 Answer (Criminal Conviction): No
- Disclosure Question 4 Answer (Civil Judgment): No
- Disclosure Question 5 Answer (Debarment): No
- Disclosure Question 6 Answer (Ownership Interest): No
- Printed Name of Person Signing: Jane Smith
- Title of Person Signing: Owner
- Date Signed: February 10, 2026
What this filled form sample shows:
- Clearly identifies the applicant as a new vendor (Sole Proprietor) by marking the Vendor Number as 'N/A'.
- Accurately specifies the Regional Center with which the vendor is applying.
- Provides a clean disclosure by answering 'No' to all required questions regarding sanctions, convictions, and debarments.
- Includes a properly executed declaration with the printed name, title, and current date.
Form specifications and details:
| Form Name: | DS 1891, Applicant/Vendor Disclosure Statement |
| Issuing Agency: | State of California Department of Developmental Services |
| Use Case: | New sole proprietor applying for vendorization with a California Regional Center. |
Created: February 05, 2026 08:27 PM
