State of California–Health and Human Services Agency Department of Developmental Services
APPLICANT/VENDOR DISCLOSURE STATEMENT
DS 1891 (7/2011)
Every applicant or vendor must complete and submit a current Applicant/Vendor Disclosure Statement, DS 1891 (disclosure
statement) as part of a complete application packet for vendorization or upon request of the vendoring regional center. The
following instructions are designed to clarify certain questions on the form. Instructions are listed in order of question for easy
reference. See 42 CFR 455.101 for additional definitions.
Overall Authority: Code of Federal Regulations (CFR), Title 42, Part 455; California Code of Regulations, Title 17, Section 54311. Welfare and
Institutions Code, Section 4648.12.
• IT IS ESSENTIAL THAT ALL APPLICABLE QUESTIONS BE ANSWERED ACCURATELY AND THAT ALL
INFORMATION BE CURRENT.
• Failure to disclose complete and accurate information will result in a denial of enrollment and/or may be cause for
termination of vendorization.
• Read ALL instructions when completing the disclosure statement.
• Type or print clearly in ink.
• If applicant or vendor must make corrections, please line through, date, and initial in ink. Do not use correction fluid.
• Answer all questions as of the current date.
• If additional space is needed, attach a sheet referencing the part and question being completed.
• Return this completed statement with the complete application package to the regional center to which you are applying.
Part 1: Identifying Information
A. Specify name of the applicant or vendor, agency, facility or organization, vendor number and service code, business
address, and telephone number of applicant or vendor submitting the vendor application.
B. Specify in what capacity the applicant or vendor is doing business. For example: The name of the corporation under
which they are doing business. This name must match the license name, if applicable.
C. List the Medi-Cal provider number, if any, of the applicant or vendor.
D. List the Social Security Number and/or the Federal Employer Identification Number (EIN) of the applicant or vendor, if
any. Enter Vendor’s nine-digit EIN assigned by the IRS in the following format: XX-XXXXXXX.
An EIN is used to identify the accounts of employers and certain others who have no employees.
For more information about an EIN, please check http://www.irs.gov
for “Employer Identification Numbers” or “EIN”.
Whenever this Disclosure Statement requests an EIN about an individual or entity, it has the same meaning.
E. Check the entity type that best describes the structure of your organization.
Part 2: Ownership and Control Interests. Use the following definitions to identify the individuals you should enter in
parts A, B and C of this section. See 42 CFR 455.101 for additional definitions.
“Indirect Ownership Interest” means an ownership interest in an entity that has an ownership interest in the applicant or
vendor. This term includes an ownership interest in any entity that has an indirect ownership interest in the applicant or
“Managing Employee” means a general manager, business manager, administrator, director, or other individual who
exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an
institution, organization, agency or business entity;
“Ownership Interest” means the possession of equity in the capital, the stock, or the profits of the applicant or vendor.
“Person with an Ownership or Control Interest” means a person or corporation that:
A) Has an ownership interest totaling 5 percent or more in an applicant or vendor;
B) Has an indirect ownership interest equal to 5 percent or more of an applicant or vendor;
C) Has a combination of direct or indirect ownership interests equal to 5 percent or more in an applicant or
D) Owns an interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation secured by the
applicant or vendor if that interest equals at least 5 percent of the value of the property or assets of the applicant or
E) Is an officer or director of an applicant or vendor that is organized as a corporation; or
F) Is a partner in an applicant or vendor that is organized as a partnership.