DS 1891, Applicant/Vendor Disclosure Statement (State of California Department of Developmental Services) Instructions

Enter the full legal name of the applicant, vendor, entity, agency, facility, or organization exactly as reported to the IRS.

Enter the vendor number and service code assigned to this vendor, using any letters, hyphens, or formatting exactly as issued (leave blank if not applicable).

Enter the complete business mailing address for the applicant/vendor, including street address, city, state, and ZIP code.

Enter the primary telephone number for the business or contact, including the area code and any extension if applicable.

If applicable, enter the legal name under which the business is registered with the California Secretary of State; otherwise leave blank.

Enter the entity's National Provider Identifier (NPI) number if available; leave blank if not applicable.

Enter the applicant or vendor's Social Security Number as reported to the IRS, if applicable.

Enter the applicant or vendor individual's date of birth.

Enter the applicant or vendor's Federal Employer Identification Number (EIN), if applicable.

Enter the corporation's assigned corporate or entity number as issued by the Secretary of State or other registering authority. Fill only if 'Corporation' is 'Yes'.

Enter the U.S. state (name or two‑letter postal abbreviation) where the corporation was legally incorporated. Fill only if 'Corporation' is 'Yes'.

Check this box if the applicant/vendor is incorporated as a corporation; if checked, provide the corporate number and the state of incorporation in the adjacent fields.

Check this box if the applicant/vendor is a governmental entity (a federal, state, county, city, or other public/government agency or organization).

Check this box if the applicant/vendor is organized as a Limited Liability Company (LLC); if checked, also enter the LLC's state of formation on the adjacent blank line.

Enter the U.S. state or other jurisdiction where the Limited Liability Company was legally formed or registered (as shown on formation/Secretary of State records). Fill only if 'Limited Liability Company (LLC) — State of formation' is 'Yes'.

Check this box if the applicant/vendor is a nonprofit organization (then choose one of the nonprofit classification options).

Check this box if the nonprofit is an unincorporated association.

Check this box if the nonprofit is a religious or charitable organization.

Check this box if the nonprofit is organized as a corporation.

Check this box if the nonprofit classification is not listed and specify the type on the provided line.

Enter the specific nonprofit classification or description when you have selected 'Other' for the nonprofit type; provide a short, clear label identifying the organization's type. Fill only if 'Other (specify)' is 'Yes'.

Check this box if the applicant is a parent or consumer who will receive vouchers, participant-directed services, or purchase reimbursements (complete Part 1 and Part 3 as instructed and then proceed to the Applicant/Vendor Signature).

Check this box if the applicant/vendor is organized as a general partnership (all partners share management and liability).

Check this box if the applicant/vendor is organized as a limited partnership (has both general and limited partners).

Check this box if the applicant/vendor is organized as a limited liability partnership (partners have limited personal liability).

Check this box if the applicant/vendor is an individual operating as a sole proprietor (unincorporated).

Enter the full name of the applicant, vendor, or authorized representative.

Enter the professional or organizational title of the applicant, vendor, or authorized representative.

Enter the date the form is signed.

Enter the individual's full legal name (first, middle, last) for the first person with ownership or managing interest.

Enter the individual's job title or role and relationship to the organization (for example: owner, partner, manager, CEO) for the first person.

Enter the individual's full mailing address for the first person, including street, city, state, and ZIP code.

Enter the individual's Social Security Number (SSN) for the first person named above.

Enter the individual's date of birth for the first person named above.

Enter the full legal name (first, middle, last) of the second person with ownership or managing interest.

Enter the job title or position (for example Owner, CEO, Manager) held by the second person listed.

Enter the second person's full mailing address including street, city, state, and ZIP code.

Enter the second person's Social Security Number as issued by the Social Security Administration (include hyphens if available).

Provide the second person's date of birth.

Enter the full legal name of the third person with ownership, indirect ownership, or a managing interest in the applicant/vendor.

Enter the person's title or position (for example, President, Owner, Manager) associated with the applicant/vendor.

Enter the person's complete mailing address including street, city, state, and ZIP code.

Enter the person's Social Security Number.

Enter the person's date of birth.

Enter the full name of the related person (as listed in Part 2A or Part 4A) who is spouse, parent, child, or sibling of the applicant/vendor. Fill only if 'First Person Name', 'Second Person - Name', 'Third Person - Name', 'Part 4A First Entry - Subcontractor Name', 'Second Subcontractor - Name', 'Third Subcontractor Name' any fields are filled (and the listed persons are related).

Enter the relationship of this person to the applicant/vendor (for example: spouse, parent, child, sibling). Fill only if 'First Person Name', 'Second Person - Name', 'Third Person - Name', 'Part 4A First Entry - Subcontractor Name', 'Second Subcontractor - Name', 'Third Subcontractor Name' any fields are filled (and the listed persons are related).

Enter the street address (and city/state/ZIP as needed) for the related person named in this entry. Fill only if 'First Person Name', 'Second Person - Name', 'Third Person - Name', 'Part 4A First Entry - Subcontractor Name', 'Second Subcontractor - Name', 'Third Subcontractor Name' any fields are filled (and the listed persons are related).

Enter the full name of the related person listed for the second relationship entry as it appears on legal or official records. Fill only if 'First Person Name', 'Second Person - Name', 'Third Person - Name', 'Part 4A First Entry - Subcontractor Name', 'Second Subcontractor - Name', 'Third Subcontractor Name' any fields are filled (and the listed persons are related).

Briefly describe how this person is related to the applicant/vendor (for example: spouse, parent, child, sibling, or other — specify). Fill only if 'First Person Name', 'Second Person - Name', 'Third Person - Name', 'Part 4A First Entry - Subcontractor Name', 'Second Subcontractor - Name', 'Third Subcontractor Name' any fields are filled (and the listed persons are related).

Provide the related person’s full mailing address (street address, city, state, and ZIP) for the second relationship entry. Fill only if 'First Person Name', 'Second Person - Name', 'Third Person - Name', 'Part 4A First Entry - Subcontractor Name', 'Second Subcontractor - Name', 'Third Subcontractor Name' any fields are filled (and the listed persons are related).

Enter the full name of the related person (the third entry) who is listed as a spouse, parent, child, or sibling of an individual named in Part 2A or Part 4A. Fill only if 'First Person Name', 'Second Person - Name', 'Third Person - Name', 'Part 4A First Entry - Subcontractor Name', 'Second Subcontractor - Name', 'Third Subcontractor Name' any fields are filled (and the listed persons are related).

Enter the relationship of this person to the applicant or to the person named in Part 2A/Part 4A (for example: spouse, parent, child, or sibling). Fill only if 'First Person Name', 'Second Person - Name', 'Third Person - Name', 'Part 4A First Entry - Subcontractor Name', 'Second Subcontractor - Name', 'Third Subcontractor Name' any fields are filled (and the listed persons are related).

Enter the mailing address (street, city, state, and ZIP) for this related person. Fill only if 'First Person Name', 'Second Person - Name', 'Third Person - Name', 'Part 4A First Entry - Subcontractor Name', 'Second Subcontractor - Name', 'Third Subcontractor Name' any fields are filled (and the listed persons are related).

Enter the full legal name of the other applicant or vendor that shares ownership or control for the fifth listed entry.

Enter the full mailing address (street address, city, state, and ZIP) for the fifth listed applicant or vendor.

Enter the vendor number and corresponding service code for the fifth listed applicant or vendor.

Enter the SSN, NPI and/or EIN associated with the fifth listed applicant or vendor (include the relevant identifier(s)).

Enter the full legal name of the other applicant or vendor who has shared ownership or a controlling interest.

Enter the mailing or business address for that applicant/vendor (street address, city, state and ZIP).

Provide the vendor number and the related service code for that applicant/vendor, if applicable (separate multiple values with a comma or space).

Provide the SSN, NPI, or EIN associated with this applicant or vendor.

Enter the full legal name of the other applicant or vendor with shared ownership (individual or organization).

Enter the full mailing address for that applicant/vendor, including street address, city, state, and ZIP code.

Enter the vendor number and service code assigned to this applicant/vendor (include both values if applicable, separated by a comma or space).

Enter the applicable identifier(s) for this applicant/vendor (Social Security Number, NPI, and/or EIN) as a continuous string of digits without dashes.

Enter the full legal name of the other applicant or vendor who has shared ownership or control.

Enter the full mailing address (street, city, state and ZIP) for that other applicant or vendor.

Enter the vendor number and the related service code assigned to that applicant or vendor.

Enter the Social Security Number, National Provider Identifier (NPI), and/or Employer Identification Number (EIN) for that applicant or vendor, as applicable.

Enter the full legal name of the other applicant or vendor that has a shared ownership or control interest (include business name if applicable).

Enter the complete mailing address for this applicant/vendor, including street address, city, state, and ZIP code.

Enter the vendor number and service code assigned to this applicant/vendor, if available; otherwise enter N/A.

Enter the applicable identifier(s) for this applicant/vendor (SSN, NPI, and/or EIN) associated with the ownership or controlling interest.

Enter the full legal name of the first excluded individual or entity (person or organization) being listed.

Enter the job title or role (for example, owner, director, agent, officer, or managing employee) of the first excluded individual or entity.

Enter the complete street address (street, city, state, and ZIP) for the first excluded individual or entity.

Enter the full name of the excluded individual or entity for the second entry in Part 3.

Enter the job title, role, or position held by the excluded individual or the representative of the excluded entity for the second entry.

Enter the full mailing address (street, city, state, and ZIP) of the excluded individual or entity for the second entry.

Enter the full name of the excluded individual or entity (as the applicant, vendor, owner, agent, director, officer, or managing employee) for this third entry.

Enter the job title, role, or position held by the excluded individual or the capacity in which the excluded entity is listed for this third entry.

Enter the full mailing address (street, city, state, and ZIP) for the excluded individual or entity for this third entry.

Enter the full legal name of the subcontractor or individual with an ownership or control interest.

Enter the job title or position of the named subcontractor or individual (for example, Owner, CEO, Partner).

Enter the subcontractor's full mailing or business address including street, city, state, and ZIP code.

Enter the percent of ownership or control interest the subcontractor holds in the applicant or vendor.

Enter the subcontractor's Social Security Number, National Provider Identifier (NPI), and/or Employer Identification Number (EIN) as applicable.

Enter the full legal name of the subcontractor or entity with ownership or control interest for the second entry.

Enter the subcontractor's job title or role (for example, Owner, CEO, Manager) for the second entry.

Enter the subcontractor's full mailing address (street address, city, state, and ZIP) for the second entry.

Enter the percentage of ownership or control interest that this subcontractor holds in the applicant/vendor.

Enter the subcontractor's identifying number(s), such as Social Security Number, National Provider Identifier (NPI), and/or Employer Identification Number (EIN).

Enter the full legal name of the third subcontractor (individual or entity) in which the applicant/vendor has an ownership or control interest.

Enter the title or position of the individual named for the third subcontractor, or the primary contact role for the entity.

Enter the full mailing address (street, city, state, and ZIP) for the third subcontractor or entity.

Enter the percentage of ownership or control interest the applicant/vendor has in this third subcontractor.

Enter the subcontractor's SSN, NPI, and/or EIN as applicable for the third subcontractor; include all applicable identifiers.

Enter the full legal name of the subcontractor or wholly owned supplier involved in the transaction for this first entry.

Enter the job title or position of the named individual at the subcontractor or supplier (e.g., Owner, CEO, Manager).

Enter the subcontractor's full address (street, city, state and ZIP code) for this first entry.

Provide the subcontractor's and/or individual's identifying numbers (SSN, NPI and/or EIN) applicable to this first entry; include all that apply.

Enter the full legal name of the subcontractor or wholly owned supplier for the second entry.

Enter the job title or role of the subcontractor or supplier (for example, President, Director) for the second entry.

Enter the complete mailing address of the subcontractor or supplier for the second entry, including street, city, state, and ZIP code.

Enter the SSN, NPI, and/or EIN of the subcontractor or supplier as applicable for the second entry.

Enter the full legal name of the subcontractor or wholly owned supplier involved in the transaction (individual or business).

Enter the job title or role of the named individual at the subcontractor or supplier (e.g., Owner, CEO, Manager).

Enter the subcontractor's or supplier's mailing address, including street, city, state, and ZIP code.

Enter the subcontractor's or supplier's SSN, NPI and/or EIN as applicable for identification of the entity or individual.